At.~TXI 4 1 r--Cr-~ ~L---r;' A& jigp ý61 ~~: -~;~VO-7 Am' 0 4ý AwA K. A-.. il, i'1 I~ *>1~ Ott C A TREATISE OF Chirir gical Operatizons, Accordirg to tiec MECHANISMA of the PARTS 0 14 T II E tH UMlANE B 0 D Y, A N 1) T HE THEORY and PRACTICE Oi the moft Learned and Experienced Su RG EO N S in PARIS. W I T H T H F. B AN DAGFS for each APPAR A T U S, AND A Defiriptio. of the INST'ýUMENTi Proper for CHIRURG ICAL OPE RAT i ONS. Tranflated from the FR E N CH of AIon. Renatus James Croiffant Garengeo t. Revis'd and Corretled by Mr. St. A N D R E. LO N D O N: Printed for T H o. W o o DW ARD, at the Hrlf-Mloon againft St. Dunflan's Church in Fleetfireet. x 7 2 3. (S I~f~~. F i t~17 t c, iii? G tSs ~x4 ~f~ ft ~ ~B PREFAC E. -H 0 U GH- many French S TurgeoLns, both antient and modern, have writ learnedly about C1hirur gicalOperations, andthe late Treat fes of MeJieurs Verduc, la Charriere, Lavauguion, and Dionis, have met with a great Reception, yet I have not Iicrlupled to publyh this W[ork for the following Reafons. THE Art ofV Surgery. which is allow-, ed to be the maJl evident, the fafeji, and nolt tifeful Part of praclical Phy/ick, is,daily imrnproved, both in its Theory and Praaice, efpecially at Paris, where many able Surgeons lirive to make them/elves eminent in their Art, and to carry it to the hig' he/f Degree of Pe ifecion. A A A PREFAC E. A N A T o M, (the Foundation of CGirur. gical PracIice,) is there cultivated with great Application; and the fiurprizing Cures daily perform"d in that City, have conv;in red allEurope that there is not any Place where Surgery is pracbfed w ith better Succefs. AF Tr ER I had exercfed that Art for oine rears under my late Father, Royal Surgeon of Vitre, a Man of Reputation; and then in fome rowns and Hofpitals of 13retagne, and in two Campaigns by Sea; the Defire of Iharing in the Glory of thofe celebrated Surgeons, and improving my felf by their Ink/rubion, moved me to go to Paris, where for the Space of many rears, I have /pared no Pains to get a full snowledge of whatever is ufeful and cuf rious in Anatomy. I followed thj/e great Mafiers zvith fuch an Eagerne/s, that beng fenjible how much I was defirous to receive their Advices, and mind all their $teps, either in Hofpitals, or any where el/e, they were fo kind as to remove wny Doubts, clear my DfJiculties, and;ftover to me thofe Motives which frequently induce them to depart from the common Method in the Cure of Dleafes. T IdEIi PREFAC-E. T EI E I R dfret ent Fays of operating ha VL lways been the principal Subje5 of my Ob/ervations; and the Reflelions I made vpon thleir d2ferent AMethods, enabled me to puiblZ/h in this [Jork fitch Explications concer miyg Chirut-gical D;feafes, and fitch Remarks upon the IManner of each O0 peratian, as are not to be found in any oa ther Book. And becaufe I am indebted to thofe excellent Pralitioners for every thing that is new in this Treatife, they have beer plea/Ed to give me leave to name them, whenever there is Occafon for it. 1 E have not enlarged upon the geieral Precepts, which concern Operations, 'tiS not becaufe I believe they are ufelefs, but becaufe they have been fiully treated of ini Chirurgical Introducdlions; and therefore I fippo/ed that thofe, for whom I write, are /fiqiciently acquainted with them. I H AVE, in the rfij Place, explain'd the Nature and Caufes of each D/eaf, its Duferences, its Symptoms, which I have accountedfor mechanically, its diagno/flic and prognoflic Signs; and before I d:fcourfe of the Operation, I Jhew by whait means it may be fometimes prevented. Afterwards I proceed to the Operation; nay, I de/cribe A3 he P REFAC1E. the dfferent Methods of operating; and I conclude with the Application of the pparatus and Bandages proper for each Operation. LaMly, I have infrted at the End of this Wfork a Jhort De/fcription of thofe Inftruments that are mo/lI necepfary for Chirurgical Operations. Wherein I have followed the Order obferved by the celebrated Mr. Arnaud, I mean the defferent Cl/fes into which he divided the fame Infiruments, when he defiribed them in the' Royal Garden of Plants.. A for the Divijons of each Infjirument, and the Denominations of its fiveral Parts, they are the Re/idt of my own Refielions, and of the Enquiries I made about them among the moft curious Artills. I HAV E endeavoured to be concife. I have al/o /fed a plain Stile, being perfwaded that a plain Narration is more proper for a Treatjf of Surgery, than a florid Stile. T o conclude, I don't pretend to pub4/h an accomplhJh'd /Fork: Self-love does not conceal its Imperfelions from me. My only De/ign is to enable young Students to reflel upon what they have learn'd from PRE FAC FE from thefamous Surgeons of Paris, ad bo infirud others, who have not had the Happinefs to fee the Operations of thofe eminent Ma/lers, nor to clear their Doubti by converfing with them. A4 -qv- 11--aarvrý~ cri Approbation of the Faculty of Ph)jick at Paris.;,i it`s *: T was a pleafant Saying of an Antient, That a great Book is a great Sin If it be fo, how many Sins have been committed in Phyfick and Surgery! One ought to think otherwife of the Treatife of Chirurgical Operations by Mr. Croilfant Garenge ot. The Operations are very orderly treated of in that Work. Each of them is attended with Obfcrv'tions neceffary for the Cure. The Author explains the Symptoms of Chirurgical Difeafes. He defcribes the old Infiruments, and mentions many others newly invented. He gives an Account of thofe Methods of operating, that are peculiar to experienced Mailers; and we have 1een moft of their Approbations. We are not afraid the Author fnould be accounted a Pilferer; and if he was a Plagiary, it \vere to be wifhed we had many Writers like him. This is the Judgment we give of this Book, after a careful Examination of it. Done at Paris, Odob. I9. I719. MrCHAEL PEAGET. LEWISDESANTEUL,. SHaving heard the Report of Meflieurs Peaget and Santeul, Doctors of the Faculty, and appointed pointed to examine a Book intitled, a Treatife of Chir urgical Operations by Mr. Croiffant Garenogeot, the Faculty give their Confcent to the Imprcfilon of it. Paris,O&Zob. 19. 1719. DEUTE Dean. Approbation of Dr. Winflow, Regent of the Fa culty of PhVick at Paris, and Fellow of the Royal Academiy of Sciences. T H IS Collction is the Fruit of a conflant Attendance upon the publick Leaures, and private Exercifes of Surgcry. The Author gave me great Proofs of that Attendance, on many Occafions. He fhew'd an carneft Defire of making himfeilf an able Surgeon, no finall Induftry to improve by the daily Obfervations, and a great Willingnels of being ufeful to the Publick. Wherefore this Work is highly valuable for the Matter contain'd in it, which is taken from the Pradice of the. moft excellent surgeons of Paris; and the Author deferves to be commended for doing them luffice, and adding his own Rcmarks with fome ingenious Refledions. Done at Paris, Novemb. 7. 1719. WIN S L o W. Approbation of Dr. Silva, Regent of the Faculty of Phyfick in the Univerfity of Paris, and Phyfician to his mqofi ferene Highnefs Monfeigneur the Duke. T H E Book of Mr. Garengeot ought the more to be commended, becaufe there are few Writers in Surgery, whom he could make ufe o aid bccuufe he is fo mniodeft and fincere as to afcribe fcribe to himfelf nothing that belongs to others; I am perfuaded that thofe, whom he frequently quotes, are fenfible their Refledions have not loft their Worth in the Hands of that Author. The Publick will doubtlefs be very much obliged to him for the Benefit arifing from his Work; and the Learned wVill read his Book with Satisfadion. Paris, Oclob. 25. 1719. S ILV A. Approbation of Dr. Col de Vilars Regent of the Faculty of Phyfick at Paris, Profe/jfor of Phar. Ynacy, and Phyfician to the King in ordinary, fivorn in the Cbatelet of Paris. I HAVE read and examined with great Care and Pleafure a Treatfr of Chirurgical Operations by Air. Croiffant Garengeot, Surgeon. His Way of dcfcribing thofe Operations (hews that he goes upon an cxaCt Knowledge of Anatomy, which alone can afford good Rules to perform them well. The effential Circumfitances mention'd by him, and omitted by other Authors; the new Method of operating, on many Occafions; more fpeedy, fafer, and more agreeable than that which was formerly ufed; and the great Number of Obfervations coll eted out of the moft excellent Mafters, ought to make this Work very acceptable to the Surgeons, and very ufeful to the Publick. Paris, May 16. 1719. Co de VItLLARS. Approbation of Dr. Alliot de Muffey, Regent of the Faculty of Phyfick at Paris, and Profefor of Pharmacy. ITTHERTO the great Number of Books, which come out cvcry Day in Phyficl a nd Surgery, have been jufly complained of. But, if they had been full of cxaxt Obfervations; if all the Arguments and Syinems, contain'd in them, had been only grounded upon a perfcd Knowledge of Anatomy, and upon Experience,'tis certain they would have affordcd a very great Benefit. The new Book of Chirurgical Operations by Mr. Croiffant Garengeot, Surgeon, contains all thofe Qualifications hitherto lb much wanted. The Arguments are exat: the Syftems are grounded upon Mechanicks, and the Strudture of the hinumane Body: the Obfervations are thofc of the beft Praditioners in our Time: the Defcription of- the Infiruments, which has been bfo imperfcCt and intricate to this Day, is very full and neat in this Treatife. Nay, the Author defcribes many new Infiruments, and others that have been perfeded. Which makes me believe this Work will be very ufeful to the Surgeons, and approved by all the Learned. Paris, May 20. 1719. ALLIOT DE MUSSE Y. Approbation of M3l1. Devaux, heretofore Mafler of the Company of the Surgeons of Paris. HAVE read with Pleafure a Treatife of Chirurgical Operations, written by Mr. Croif fant Garengeot, Sirgecon, of the Province of Bre of Bretagne. Thofe Difcafes which require the Hand of a Surgeon, are explain'd by that Authir in fuch a manner as fhews him to be well skill'd in Anatomy. The Operations are defcribed with great Exadnefs in that Treatife. It contains alfo many ufeful Remarks upon the different Methods of operating, made ufe of by our belt Praaitioners, and befidcs, a fhort Account of fieveral extraordinary Cures happily perform'd by the ingenious Inventions of thofi excellent Mafters. Laftly, the Explication of the Chirurgical Inflruments, to be found at the End of this Work, being as perfe& as can be, makes me *believe it will be of great Ufe to young Surgeons in the moft difficult Cafes, fince nothing more exat and infirutive hath been hitherto publifhed upon pratical Surgery. Such is my Judgment about this Treatife, after having read it with the Attention it dcfcrvcs. Paris, May I. 1719. DEVAUX. Approbation ofMr. Poncelot, heretofore Mafier of the Company of the Surgeons of Paris, and Demonfirator of Anatouy and Surgery. I H A V E carefully read the Operations of Surgery, which the Author offers to the Publick. His conflant Attendance upon the beft Mafters in that Art, of which I have been a Witnefs for many Years, whilft I had the Honour to profcfs Surgery at St. Come's, in the Schools of Phyfick, and in the King's Garden, is a fufficient Inducement for me to allure young Surgeons that this Work will be ufeful to them. Paris, Novemb. 3. 1719 -PONCELI t, Approbation of Mr. Coflz, fworn Surgeon of Paris, heretofore Majier of his Company, and Dainonflrator of Anatomiy. N OTH IN G can be more inftrudive upon Chirurgical Operations, than the Treatife which Mr. Croiffant Garengeot, Surgeon of the Province of Bretagne, has lately given us on that Subjed. Every thing in it is agreeable to the Precepts of a good Pradicc, and fupported by jufl and $blid Arguments. He defcribes the Operations with great ExaFnefs, and likewife thofe Infiruments, that are nofl proper for them. I heartily wifh Surgeorns would read it with Application. Every thing in that Book is grounded upon a perfed Knowledge of Anatomy, and the Expericnce of the greateft Mafiters. Such is the Judgment I give of that Treatifg, after a careful reading of it. Paris, lIay [5. I719. Cos T Z. Approbation ofL M. Petit, heretofore Alfqier of his Compan!y, Demonfratcr of Anatomy and Singery, and Fellow of the Royal Academy of Sciences. A F T E R the reading of a Manufcript intitled, a Trearife of Cihirurgicil Operations, &c. by Mr. CroJfant Garengeot, I thought it was not fo proper for me to approve the whole Work, (conftderng that the Author has inferred in it feveral of my Obfervations, and a Defcription of fome Infiruments of my own Invention,) as to give my Confent to the Impreflion of it. I am willing to favour the Author's Defign of being uifeful to the Pub Publick. He will doubtlcfs fucceed in that Defign, if thofe things which he has borrowed from im, do not depreciate the excellent MAaterials with \vhich thcy are to be found. Paris, Mlay 13. 17I9. P E T IT. 1pprobation of M. L. Roux, fworn Surgeo i of Paris. H A V E read very carefully, and with great Pleafure, a Manufcript of Mr. CroiJant Garengeot, Surgeon, containing a Treatife of Chirurgical Operations, and a Jhort and exa/ Defcription of thofe Infiiruments that are made ufe of toperformn them. I find bythe Theory of this Treatile, that the Author is a perfect Maflcr of his Subjct, and it appears by the great Number of Cbfervations, and extraordinary Cures mention'd by him, that he is very well acquainted with every thing that concerns the Art of curing Difeafes. We may therefore entertain great Hopes of that Surgeon, and believe he will hereafter very much contribute to the Perfeation ofSurgery, lince he has got the Efteem of the Learned by his firfl Elffay. Paris, June I. -1719. L. Rou x. THE THE T H~ E ABLE ofCHAPTERS. hap. i. F Operations in general, tIr Definition and Divoni01, Page r,hap. z. Of ounds in relation to Sutures, 3 ap. 3. Of Sutures, 'with fome Preceptsfor the drejing aWound, 19 Chap. 4. Of the Gafroraphy, 48 of the Bandage, known by the Name of N A P K IN and SCAPULARY, 8S Chap. 4. Of Hernias, 84. hap. 6. Of the Operation of the Bubonocele, and the crural Hernia, 112 ap. 7. Of the Operation of the compleat Hernia, 120 hap. 8. Of the Operation of the EXOMPHALOS and ventral HERNIAS, I 34. ap. 9. Of the Drop/y, in relation to the PAR ACEN TES IS, I 4.1 ap. io. OftheOperationof the PARACENTES S, or Punsfion Sof the Belly. Iyr 1ap. II, of the Hydrocele, 164. CIap. 12. Of the Operation of the Hydrocele, 168 Chap. I 3. Of the cajlration, in relation to tho/e Di fafes which require that Operation. 178 bap. 14. Of the Operation of the Caf ration, 1 82 ap. 15. Of the Stone in the Bladder,inrelation to Lithotomy, 187 ap. 16. Of the Method of founding, in relation to the Difeafes of the Bladder, 195 Chap. 17. Howv the Patients ought tobe prepared for the Operatio; of Lithotomy 207 Cap. 18. of the Operation of Lithotomy, or the Extragion of the Stone 1o Cap. 19. Of the Stone in the Urethr.a, andtheOperations properfor it, 228,ap. 20. Of the Phiniofis, 23 Chap. 21. Of the Operation vf the Phimofis, 234 (lap. 22. of the Paraphimofis, 239 ap. 23. Of the Operation of the Paraphimof's, 242 Chap. 24. Of the Fi ula in Ano, andAbfceffes, which happen 'V that Part, 247 Mhap. 2z. Of the Operation of thofe Abfcefs, which happen in the ANUS, 1: 1 ap. 26. Of the Operation of the Fiflula in Ano, 256 p. 27. Of the Wounds and Ab/fcefes of the Breaf4 in relation toa he Epyema, 263 Chaja The T A B LE of C H A P T E R s. Chap. 28. Of theOperation of the Empyema, 27! Chap. 29. Of incifled Tumors, known by the Names of Wens, Glands, Scirrhuls, Cancers, and thofe called by the Antients Atheroma, Steatoma, and Meliceris, 278 Chap. 30. Of the Operatiov of the Cancer and incýfedTumors, 289 Chap, 3 1. Of the Squincy, in relation to the Bronchotomy, 299 Chap. 32. Of the Operation of the Bro;chotomy, 304. Chap: 33. Of the Hare-Lip, 310 Chap. 34. Of Cancers,. and Puflules, which happen fometimes in the Lips, 32 1 Chap. 35. Of the Polyppu, 324 Chap. 36. Of the Operation of the Poylpus, 329 Chap. 37. Of the Fifula Lacrymalis, 333 Chap. 38. Of the Operation of the Fiflula Lacrymalis, 342 Of the Bandage, caI'd the fingle Eye, 353 Chap. 39. Of ounds of the Head and of Frac7ures of the Skull, in relation to the Trepan, 3059 Chap. 4o. Of the Operation of the Trepan, 3 85 Of the great Couvrechef, or the fluare Coureechef, 4o Chap. 41. Of the Aneurfm, 409 C(hap. 42. Of the Aneurifim, 417 Chap. 43. Of the Wounds of Tendtons, in relation to their Sutures, 433 Of the Triangular Scarf, 430 Chap. 44. Ofithe Suture ofthe Thdons, 439 Chap. 45. Of the Panaris, Chap. 46. Of the O eration andCure of all kinds of Panaris's, 457 Of the Bandage 'with eighteen Heads, 465 Chap. 4.7. Of the Gangrene andSphacelus, in relation to Amputatiod, 467 Of the Cure of a Gangrene, 476 Chap. 48. Of the Amputation of the Leg, 482 Of the Bandage call'dthe Capeline with one Head, 496 Chap. 49. Of the Amputation of the Leg,e as invented at the Jame Time by Mr. Sabourin, a Surgeon of Geneva, and Mr, Verdvin, a Dutch Surgeon, 498 Chap. 5o. Of the Amputation of the Thigh, 503 of the Bandage proper for the Amputation of the Thigh, 9o6 Chap. 5 1. Of the Amputation of the Fingers, o o7 Of the Ba;zcgeproper for the Amputation of the Fingers, 0og Chap. 52. Of the Amputation of the Fore-arm, 51 Of the Bandageproper for the Amputation of the Fore-arm, Chap. 53. Of the Amputation of the Arm, p 1 Of the Bandage proper for theAtmputation of the'Arm, I8 Chap. 54' Ofthe Amputation of the Arm in the Joint, 521 Of the defending Spica proper for the Amputation of the Arm in the Joint, 5%s A TREATISE OF THE Operations of Surgery: CHAP. 1. Of Operations in general, their "'ifnition, and 'Divifon. H1E Operation df Surgery is arn indufirious Motion of the Surgeon's Hand, upon the Parts of T the humane Body, in order to refore or preferve Health. Mo0s8T of thofe, wkho have writ concerning the Art of opeo rating in Surgery; confidering the Opetations according to their Nature, or rather according to their Genus; have divided thenm SsInto 2 A Treatf eof the into four different Kinds, which they call Synthefis, becaufe it re-unites thofe parts that are feparated; 'Dihrefis, becaufe it divides thofe parts which are united contrary to the order of nature; Exxrefr, becaufe it removes what is extraneous to the Body; and Rrothets or Hpothejis, becaufe it adds fome external Inftrument to the Body, in order to fiupply the Want or Defel of fome of its parts. Not contented with thofe Divifions, they have further fubdividcd every Kind into many more, and left us fuch a confufed Number of Sub-Diviftons, that one does not know what Courfe to take. T H E three firfl Kinds of thofe Divifions, having fuch a firiat dependence on each other, that they generally go together, and are to be met with in mroft OperLions; we fhall lay afide thofe fcholaffical Terms, which rather perplex than inflruet, and fhall keep only to the Etymology of each opmration, which is derived from the part on which it is performed; or from its Refemblance to fome other thing, as it will be faid hereafter. SA ST, Y, Without further infifting upon thofe general Notions, we fhall lay down thefe Rules; that all chirurgical Opcrations ought to be performed fpeedily,,eja/ly, and cdexterou/y. But to make Ufe of thofe Precepts, a Surgeon ought to know that the Operations confift of two Parts ' the one concerns the Theory, and the other concerns the Pradice. THE I firfi takes in the Knowledge of the Difcafe, its Caufe, Beginning, Progrefs,- State, and End, and of fome other Circumitances, which ought Operations of SU R G R Xt1 3 ought to be known before one goes about the Operation, that one may judge of the Neceflity of its Performance, and what Remedies are proper for the Difeafe: This is to be learned by the reading of good Books, and by an accurate Kriowledge of Anatomy, without which 'tis impoflible to be a good Surgeon. THE Pradice confifis in the Method of prcpa-i ring the Apparatus, in the Knowledge of Inftruments, the manner of operating, and other Particulars to be learned only by frequenting good Surgeons, by reading the Obfervations of abld Praaitioners, and by a conflant Attendance in Hofpitals. CHAP. IIL Of Wour;nds in Relatio* to Sutures' Y a Wound we mean ai Solution of contirinu B ty, or a Divifion of the foft Parts of the Body, recent and ftill bleeding, proceeding from art external Caufe, fuch as cutting, bruifing, tearing, and pricking, whereby the natural Difpofition of Parts is altered. B E PO R E I mention the Re-union of Wounds, it will not be improper to fay fomething of the Manner how it is effeaed. T H E ReCeaions that have been riade tipon Anatomy and Pathology, teach us that our Body iS only a Compages of Veffels, and that all the Parts.z Arc 4 A Treatife of the are formed by the different Figure and Difpofition of thofe Veffels. Hence it is cafy to apprehend, that if the Parts appear to us different from each other,' that Difference proceeds only from the various Difpofition of the Veffels of which they are compofed, and by a neceffary Confequence, that their different Difpofition occafions in each Part feveral Spaces and Pores of different Figutes: from w\hence it ought to be inferred, that the nutritious Particles of the Blood, which are to be conveyed into thofe Veffels, muff neceffarily be'difpofed and moulded according to the Configuration of the Pores and Tubes of each Part. B Y thofe Veffels I only mean elrifick Fibers, either flcfhy, nervous, or membranous, through which different Liquors pafs; and Health depends upon the Equilibrium between the Tubes and the Liquors contained in them. Wherefore a Difeafe confifts only in the Diforder of thofe Veiffls, or in the Alteration of their Fluids. B Y Fluids I only mean the Blood, which is compofed of feveral Principles, and appears to, the Eye under the Form of two Subftances, the one red, and the other white. This latter Part of the Blood is the nutritious Juice: It ferves to maintain and repair the Parts. AFTER thefe Explications, I think it will not be difficult to apprehend, that Nutrition, with Refpet to Wounds, is a continued and prolonged Generation of Fibers, either cut or lacerated, which can only be effeted by that white, baltamick, and vifcous Part of the Blood, which we call the nutritious Juice, and is different in every Part, becaufe the Operations of SuRGE RY. J the Tubes of the feveral Parts have different Configurations, as has been already faid. THi s Trutlh is confirmed and fupported by the Inflance 'of Vegetation, fince by putting many Grafts of a different Nature upon one Stock, they bear differunt Fruits, though they only receive the famre Sap RIut by the different Configuration of the Fibers of differcnt Grafts, it is differently prepared, and confcquently produces different Fruits. WHEREFOP E if the Bone be divided, the Juice containred. in the bony Fibers, reaching their Eids, oriows iard, 'firetches out, and fills up the Space made by.the Divifibn. The fame happens in all the t'. her Paris, 'as we obferie in thofe Womunds, vwherein the Skin is whollyA tieftroyed; for we fee that the Scar begins at the Circumference of the Wound, at the fame timetThat the Middle is much more tender, becaufe the Fibers, firetching themfelves continually by the Molecule of the nutritious Juice, grow leffer, and by that Means make the Middle of the Scar'thiiiner. On the y6ntrary, in thxoMc Wounds wherein the Skin is not wholly deftro'ed, as, in a Burn, the Scar forms it feilfon all Sides. F RoM whence it ought to be inferred, that a Surgeon, in the Re-union of Wounds, muft endeaVour to rcdify that Sap by ufing general Remedies, when it is altered, and to reflore the divided Fibers to their former State, with the help of Topicks, by making them pliant, and fecuring themn from the brnpreffion of the Air, which may alter the good Conftitution of the nutritious Juice in the Fibers that are cut or lacerated. And the beft Proof that can be given to fhew that nothing can B.3 bc 6 A Treatife of the bc more pernicious to a Wound than the Air, is, that though no Remedy be immediately applied upon Fracures, yet they will reunite if they are not expofcd to the Air; bccaufe the natural Heat gives to the nutritious Juice of the Bone, the hard Temperature it ought to have to heal up the FraiCures. T H ou G H what I have faid hitherto concerning Wounds, does manifcftly prove that the Reunion is a mere Operation of Nature; yet in fome cafes Art has a great Share in it; and if a good Surgeon did not endcavour to remove the Obftacles, which hinder the Conjuntfion of the divided Parts, Nature would frequently work in Vain. THOSE Obitaclcs are either foregoing or fubfcquent. The former are thofe, which precede the Wound, viz. as I have already faid, the different Alterations of the nutritious Juice. The fubfcquent Obflaclcs are thofe that happen after the Wound, fuch as Convulftons, cDelirium's, Contufton, lofs of Subltance, Hemorrhagies, extraneous Bodies, the great diftance of the Lips of the Wound, and the fituation of the Wound it fclf. A s fer Convulfions and 'Delirium's, the only means to cure them are Phlebotomy, Purging, and fome other Remedies taken inwardly. T H E Contufion is an Obftacle, which hinders the Lips of a Wound fitom joining together, and cannot be removed but by fuppuration. A Contufton happens feveral ways, whether the Wound be made by a bruifing or cutting Infirument. The firft tears and bruifes the Parts, unlefs the Blow be flanting, as it happens fometimes in Wounds Operations of S U R G E R Y. 7 Wounds of the Head; and then, as I Ihall fay hereafter, a Suture ought to 'c zmade. But it would be a very great Fault to make Sutures in the firft Infiance, fince that Obitacle, viz. the bruifng of tihe Flefh, can only be romoved by applying fiich Remedics as will excite a gentle Suppuration. If the bruif'ed Wound happens to be in thofc Parts, that are commonly uncovered, fuch as the Face and the Arms, it muft be flitched, without tying the Threads of the Suture, till the Suppuration is well over, at which time the Threads are tied in ord r to bring the Lips together. TH 0 U G H the Wound be made by a fharp Inficrument, it frequently happcns that th LEdge of Pich Tools being foimcwhat rough, by cutting the Parts, bruilts them alfo, and caufes a Cotuflion in the Lips of the XWound, which is generally attended with an Inflanmation,and contfqcjueintly with a Suppuration. Jleeding affords every D.-y Inflances of this Fad; for when a Vein is opened with a bad Lancet, the Orifice is not clofed up immediately, but it forms a littlce Tumor attended with an Inflamationf, which on. mutt not pretend to cure fpeedily by the ufe of Deficcatives, but ra ther by excitinr a gerntc Suppuration, which cloftes up the Orifice in two or three Days. THE Lofs of Subitance i, ore of the chief things that preventthe re-union ok WTounds, by rcaFon of the difficulty of bringing the Lips together; for before the Wound be reunited, it is neccfary to repair the Parts. Howevcr, t'his Ruhle is liablc to fbme Exceptions, as when the Wound happens il thofe Parts, which arc very ycilding;a fiich as the Lips 13 4 and 8 l"A ieat~/e of the and the Breaft, which will afford us fome Inflan6 ces of 1< hereafter Ti-E - Hcmorrhage- is fuch a accident, that it deprlves the op'ifator of all the means, WVhich Surgery affords to reunite wounds, uTilefts it be firft re, moved. This requires a great deal of attention; for when the opened Artery is furrounded with boo ny parts, it frequently falls out that no remedy'-n be applied, as ia theextirpation of thý Po0ypus j and the Patient dies by the effufion of blood. This truth is alfo confirmed by the drawing of teeth, out of which a great deal of blood does foi'etimes iffe; but it may be flopped by compreffion. T H E R E are twvo forts of Hcmorrhages, the one ordinary, and the other extraordinary. The firft is nothing elfe but what happens in all Wounds; becaufe there are no capillary Veflels but what ýwill occafion a fmall Elfufio-i of blood in the leaft Vounds. But by the latter we mean, a continual Effufion of Blood froni fome large VOflels; and there are two Hemorrhages of this Kind, the one proceeding from the Arteries, and the other from the Veins. W E have three wayTs of floppingc the Blood of an Artery, viz, the Comprefion, the Application of Stipticks, and the Licgature. BU T if there was aniXextraneous Body,in the Wound, and a confiderable. Hemorrhage of an Artery, muff the Blood be flopped before the extraneous Body be removed? The anfwer is, that in this cafe the Ligature is the only thing that can be praLifed: And fuppofe a Surgeon was fo fortunate as to make it well, the extraneous Body being drawn out would tear the VeIki, and oicafion a new Hemorrhage: Operations of SUR GER.. 9 rhage: And therefore Mr. Petit, fworn Surgedi of Parzir, heretofore Maiter of his Company, De. mnionftrator of Anatomy and Surgery, and Member of the Royal Academy of Sciences, advifes to take out the extraneous Body before the ftopping of the Blood. And if the Hemorrhage is very confiderable, the runnng of the Blood ought to be governed by the Tourniquet, and then the extrancous Body muft be drawn out, and the Blood flopped. THE Blood running from the Veins flops of it klf, -when after a large fffifon, the Part is difehdirged, or elfe, one ought to ufe tthe Compreffi ro,.&c. EXTRANEOUS Bodies proceed from within or from without, and frequently from both at the fame time. The former are either a Ball, the Ram, or feveral other things. The latter are parts of the Body it fklf, being three in number, -viz. bruifed FleTh, Fragments of Bones, and coagulated Blood. I fhall hereafter give a particular Account of all thofe Matters. THE Diffance of the Lips of a Wound, and the Mobility of the Part, are further Obitacles to the Reunion. The Wounds of the Inteflines afford us an Inltance of it; for having no fixed Point, and confequently it being impolfible to keep the Lips of the Wound together, the nutritious Juice will fall either into the Cavity of the Inteftin, or into that of the Abdomen. THE laft thing that prevents the Reunion of Wounds, is their Situation; for if it happens in the Aponeurofis of the Muicles, the Suture would occafion fad Accidents, whereby the Surgeon would 10 A Treat~ of the would be obliged to cut it. If the Mufcle be cut near its Aponeurofis, no Suture ought to be made in it, as, for Inflance, in the temporal MVlfcle, becaufe its Fibers being very fhort, and, as it were, funk into a double Membrane, wvhich is the Pericranium, and the Expanfions of the frontal and occipital Mufcles, they cannot ifretch themfelves: But a Chin-Cloth ought to be put on; the Patient muff not be allowed to fpeak, and muft live upon liquid Aliments, which he takes with a perforated Spoon, the End of which is made flat; and with the help ofCompreiffs the Lips of the Wound are brought as near as poflible. HA V IN c, mentioned thofc M cans which Nature makes ufe of to re-unite the divided Parts, and to repair the Parts, when there is a Lofs of Subftancc; I (hall in the next Place mentionr the feveral ways ufed by the Art of Surg ry to effe1 that Re-union, uviz. the Situation of the wounded part, the Bandages, and the Sutures. T H E R E are in Surgery three Sorts of "ituations; one to know the Difeafe, another to operte; and lafily, that which the part cugh to be in iiafter the Operation. All thofe Situations concern the Body or the Extremities. As to the Body, t Head ought to be higher than the Breaf, anid the Breaft higher than the Belly. As for the upper Extremity, the Arm ought to be placed aginflt the Ribs, the Fore-Arm ought to be half bended, and rather prone than fupine, the Wrift more firetched than bended, and the Fingers more bent than ftretched. As for what concerns the lower Extremity, the bending of the Groin ought to be lower than the Kne, Oper!t;ons of SOURGA Y.. It Knce, and the Knce lower than the Foot; as alfo the Wrift higher than the Elbow. However there ie f;or-e Wounds, which require an oppofite Situation, in order to be re-united, as I fhall obfcrve hcrcai'ter. T H E fccond way of re-uniting Wounds conThis in the Bandages, which are three in number, viz,z. the Contcntive, the Incarnating, and the Expuiiive. T H firf of thofe Bandages, which is called Contcntive, fervcs only to contain the Dreflings; and therefore it ought not to be rolled ftrait. IN order to make it, the Surgeon ufes a Band of different Breadths, according to the wounded Part: That Band muff be rolled with one Head: It muft be gently applied on the Dreflings, making fome Circulars, Edgings, Spirals, and Turn-overs, &c. according to the Nature of the Wound, and Figure of the Part. THE fecond of thofe Bandages, which is named Incarnating, is proper for a recent Wound, free from the Obftaclcs juft now mentioned, and the Diredtion of which is according to the Length of the Mufcle. Before that Bandage be applied, the Depth of the Wound ought to be examined as foon as poflible, that the Air may not have Time to aft upon the divided Fibers; and if it be confiderable, the Surgeon brings together the two Lips of the Wound, and applies on every Side a longitudinal Comprefs, which he orders a Servant to hold in that Situation. This muff be done every time the Drdflings are taken off; for without this Caution, the Bandage would moft times prove ineffedtual, of I z A Treat.f of the Of the uniting Banidage. Taur Bandage, Which has been called uniting or incarnating, is mad,v itha Roller with two [leads, iplit in the middle accdrding to its length, and two, three.or four Inches broad, accordin to the pti on which it is to be applied. The Operateo'. lays the Roller on the oppofite Part ofthe Wounid, and then brings the two Heads over the Wound itfelf, in fuch a manner that the middle of the Slit correfponds exadtly with the middle of the Wound. Afterwards he paffes one of the Heads thro' the Slit, and holding b9th Hcads with his Hands, he oblerves whether the Bandage be well placed to reunite the Lips of the Wound. He makes an end of that Bandage with fome Circumvolutions round the part,till the'.Xoler' be wholly taken up. IF theAVound was very long, I would advife the Suirgeon to fplit the Roller in three feveraplaces, that he may firft reunite the middle 6f the Wound with the iirft Convolution,and then the two Extremities by the following Convolutions. -Mr, Arnaud, the King's Surgeon in his Court of 4 Parliament,,heretofore Mafltr of his Company, and eiemontfrator of Anatomy and Surgery in the Royal Garden,fays that a Bandage may be made in fuch a manner as to have the fame Advantages, without its Inconveniencies.` In order to this, he takes a Robl ler with two Heads, applies the middle of it. 6bliquely upon the Part oppofite to the Wound,'"nd then brings the Bandage obliquely bver the Wound, and having made two or three fnch Conyolutions, he conveys one of the Heads about the upper part of the Operations of S R G E RY. 1) the Wounded Limb, and the other about the low. er Pait. Mr. Petit does very much approve of that Bandage, but he will have the Roller to be fplit, and the two heads applied obliqucly, in order to avoid the Inconveniencics that attend the fipft method.The longitudinal ComprcffTs applied to both fides of the Wound make that Bandage ftill more effeaual; but then, as I have already obfcrved, theWound ought to be deep for, in fuperficial Wounds, the compreffes are ufclcfs and even hurtful, and a fingle bandage may anfwcr all the Indications, That Bandage is alfo very proper for the Extremities, where there has been a great Abfccfs,and where the Fat, lying in the Interflices of the Mufcles has been exhauffed by Suppuration, and confequently leaves empty Spaces between the Mufcles; for by thofe oblique Convolutions, it brings together all the feparated Mufcles, and prevents the forming of Sinus's. THE third Bandage, called Expulifve, is proper for a fiffulousWound, the bottom of which lies above its opening, in fuch a manner that the Matter by its natural Defcent may continually come out. SURGERY affords us three ways of reuniting this fort of Wounds. The firft and the eafieft,.is the Bandage juft now mentioned; but before I defcribe it, I muft fuppofe a Wound attended with all the Difficulties proper to give a great light to this matter. LE T us therefore fuppofe a fiftulous Wound, the bottom of which lies in the lower part of the Arm, and the opening in the middle part. The Operator upon this occafion muff fearch the Wound, in order to know whether it be free from the Obftacles above-mentioned; and then he muft extra& the * Blood, 14 A Treatfe of the Blood, that may be in its Bottom, and in the room of it pour fome Drops of a uniting Balfam, uhch as that of Judea, or rather that of the Commaidyur. AF T EW A R D S let him apply three graduated comprefies. The firft ought to be laid from the Bottom of the Wound, within two Lines of its Opening. The Second muff be laid upon the firift, and reach from the Bottom within an Inch of the Opening, fuppofing the Sinuts to be long enough. Lattly, the third flhall reach from the Bottom within two Inches of the Opening. Thofe Compreffes thall be kept on with the expulfive Bandages, fo called, becaufe when it is applied upon the three Compreffis, the Dimcnfions whereof I have juft now defcribed; it begins firft with prcfling the Bottom, and drives out of it what might hinder the Re-union, the purulent Matter, for inftance, and fo continues fucceflively to re-unite the remaining part of the Wound. INSTEAD of the graduated Compreffes laid all along the Sinus, Mr. Petit makes ufe of Lint applied outwardly, as if he was filling a Wound, becaufc the Roller going over the Lint, preffis the Simus in all its Parts. I Norder to make that Bandage, the Surgeon takes a Roller' with one Head, with which he begins the Bandage, making a Circular fomewhat lower than the Bottom of the Wound; and afcending he ends by Edgings, where the firft Comprefs ends. THE Operator ought to mind what I have faid, that this Bandage is only proper for a fiftulous Wound, the Bottom of which is higher than the Opening; and becaufe the Wound I initance in, has Operatons of SUR GERYx. II has its Bottom under its Opening, it ought to be remedied by the Situation. Wherefore, contrary to the Rules I have prefcribed about Situations in general, the Surgeon muff raife the Elbow, in fuch a manner that it may be a little higher than the Shoulder, (fuppofing the Patient to lie down,) that the purulcnt Matters may come down towards the opening of the Wound. I muft obferve that this Bandage ought never to be ufed, when there is forne ground to expect a Suppuration, and when there are fome Fragments or Splinters of Bones, or fome other cxtraneous Bodies in the Wound; in a word, when there is any of thofe Obitacles above-mentioned, which may hinder the Reunion. A A GAI N, let us fuppofe a Thruft with a Sword,or any other Infirument, that makes an Opening; for inflance, in the internal and lower Part of theThigh, which penetrates into the Articulation, and that it be attended with a Swelling and Inflammation, and even with an Abfcefs in the lower Part of theThigh, in the whole Knee, and in the Ham; pretty long Compreffes ought then tobe applied below and about the external and hinder Part of the Thigh; and becaufe the greateft diforder is about the Ham, the Operator ought to have a very particular regard to it, and lay in a great deal of Lint, which prefling the Abfcefs in all its Parts, may drive the purulent Matter towards the Opening: this will fucceed fo much the better, as the Surgeon has a more exa& Notion of the Fugure of the Sinuts. A Comprefs, and the expulfive Bandage, muff be laid over the Lint. I HAVE lately opened a very confiderable Abfccfs under the Arm-pit: all the Fat under the Petorat 16 A Teat fe of the tal aid the Serratus antiquus minor was confumed; nay, there were fome Cavities, that reached above the Clavicula, and under the Scapula; and I cured it in four Weeks with that ingenious way of dreffing fuch an Abfcefs. But fometimes this Method of managing a fiftulous Abfcefs does not fucceed, efpecially when the Bottom of the Abfcefs is below the Opening: in fuch a Cafe, one muft think of fome other Means. THE Second way of proceeding in thefe forts of Wounds, is the Counter-opening, that one may pafs a Seton, to carry off the purulent Matter, which ftagnates in fuch Wounds. This Operation may be performed two Ways. Firit, if the Fif/ula allows the Surgeon to introduce the fore-finger, and if the end of the Finger touches the bottom of the Fifula, he may make the Counter-opening upon it and to prevent the cutting of his Finger, he puts a Thimble upon it. That Thimble muft have two fmall Rings, that it may be faftened to the Finger with two Threads let into them, for fear it fhould remain in the Sinus, when the Operator withdraws his Finger. Secondly, when the fiftulous Cavity is fo deep or fo narrow that the Finger cannot be introduced into it, the Counteropening may be made with Mr. Arnaud's Poig nard, which is a flat filver Probe, about half a Foot long. There is a kind of Hilt at the upper Part of it, and at the lower End there are two Holes oppofite to one another. There is in that Probe a Stilet of the fame Figure, only it has a Button at the upper Part, and at the lower End a Lancet jutting out of the Probe about the breadth of one Tinger. Mr. Tetit has added to that Inftrument a Spring, Operations of S U RG ER Y. 17 Spring, which draws back the Lancet into thd Probe; and there is upon the Probe a Groove to convey a Biftouri, or Cizars, in order to open the whole Sinus. The Operator conveys that Probe armed with its Stilet into the Bottom of the fiflulous Ulcer, and then he thrufts the Stilet, which by means of the Lancet makes on opening: He pufhcs out the Probe through that Divifion, and draws back the Stilet only, to pafs into the Holes of the Probe a Seton, which mufft be f0metimes round like a Wick of Cotton, and fometimes flat, like a Fillet, according to the Difpofition of the Woundi into which it is to be let. Afterwards the Surgeon withdrawing the Probe, brings the Seton all along the Wound. That Seton mufft be changed at every Drefling; which may eafily be done by tying the End of a new Seton to the End of that which is in the Wound, efpecially to the uppermoft, in order to bring it out through the Counter-opening, and to facilitate by that means the Difcharge of the Matter; which can be better effe&cd in Gun-fhot Wounds than in others. WHEN the Surgeon does not think fit to pafs the Seton, he muft then make fome Inje&ions. Here follows a wonderful one. TAK E about half a Pint of Barley-water, one third of the BalJfa of Fioraventi, and an Ounce and half of the Commandeur s Balfam. W HEN the Seton is made ufe of, it ought to be removed as foon as the Suppuration is well over; and an Inje&ion ought to be made in the room of it. I generally happens that the uppet Orifice of that fort of Wounds dries, and clofes up pretty C jfaft Sg8 A Treatfe of the faft: This a Surgeon ought to promote as much as he can, fince the Matters tend downwards, and comes out at the inferior part, THE Bandage of fuch Wounds muft be only a contentive one. THE third way of curing fiftulous Wounds and Ulcers, is to open the Wound in its whole Length; and a Surgeon is indifpenfably obliged to ufe that Operation, when there are fome Fragments or Splinters of Bones, or when the Bones are foul in fiftulous Ulcers. In order to open that fort of Ulcers, the Operator makes ufe of a hollow Probe, clofed at its lower End: He conveys it with the right Hand into the Bottom of the Sinus and then takes that Probe with the left Hand, and raifing it a little, he brings it all along the inward Surface of the Wound, in order to ftretch out by that Means the Part that is to be cut. Afterwards he takes with the left Hand a crooked Biftouri, the Blade of which is faftencd with a Fillet, to make it more fleady, and laying the Fore-finger upon the Back of it, he conveys it into the Groove of the Probe, which he holds fait with the left Hand, and cuts the Parts he meets with, conveying the Inftrumcnt all along the Groove without leaving it. The Surgeon having carried the Operation thus far, leaves his Infiruments, and introduces his Fore-finger into the Opening juft made and if he meets with fome Bridlings,. or if the Incifion does not reach the Bottom of the Wound, he conveys the Middle-finger, or the Fore-finger of the left Hand, under what remains to be cut in the Sinus, and with the help of that Finger moving one of the Branches of his Scizars, he makes an end of the Operation. B ESIDE L Operatin of SURGER Y. I19 B E S I D E s the Obfcrvation of all thofe Circumnflances, the Surgeon mnuft alfo obfcrve wheCher there are any Fragments of Bones, or loore Splinters, which do not adhere to the 'Perijofieum, and then looking upon them as l0 many extraneous Bodies, he mufi cxtract thcin; and if the Operation was made in confequnce of a fiflulous Ulcer, and the Bone is a little carious, he may ruginate it immediately, that the Patient may not be troubled a Iccond time with the Sight of our Initruments, which never fail to frighten him. WHAT Remains is to lay on the firf dref-' fing; and in this Cafe moft Praditioners make ufe of dry Dozels to flop the Blood by filling the Wound. Mr. Arnaud rather chufcs to ufe fobne Pieces of Linticn half worn out, pretty fine and ragged. Compreffes and a contentive Bandage ara laid upon the whole. CHA P. I Of Sutures, with fome Precepts for the drffing of Wounds. T HE third way of re-uniting Wounds recent and ihill bleeding, confifts in Sutures, which a Surgeoli muft have recourfe to, when the Situation of the Part, or the Bandage, cannot by themrfelves bring the Lips of the Wound together, bebecaufe it is one of the fafeff Means that Surgery can afford to re-unite the divided Parts. A STUR E, confidered as a chirurgical OperAtion, is a Seam.made in a XWound, in ordet to reanitc its Win 2o A Treatfe of the WIT o UT minding the confufcd Number of Sutures, which the Ancicnts have left us, and without infifting too much upon the Reafons alledgcd by the Moderns to rejet many of them, I fhall only mention thofe, that are in ufe among the moft famous Praditioners of 'PariS. IT is ufual to. make two Sorts of Sutures, the one with feparate Stitches, that ferves to unite the divided Parts; and therefore it was called by the Ancients.uniting or incarnating. The other is made with continued Stitches, and hinders a Fluid from going out of his Cavity; and for that Reafon we call it the reftrindive Suture. I r is alfo ufual to make two Sorts of uniting Sutures: The one is called a true Suture, and the other a falfe one. The former can only be practifed with the help of Thread and Needles: The latter, on the contrary, does not want any chirurgical Infirument, and confcquently the Ufe of it is not attended with any bleeding; and therefore it is called a dry Suture, It is not much pradtifed among the Moderns, who pretend it is only proper for fiuperficial Wounds, which affed only the Skin. This is true, when that Suture is made with fmall triangular Plaifters, as it was pratifed by the Ancients: But when a Surgeon makes ufe of large Plaif ers, which reach pretty far beyond the Wound, to draw the Flefh as' well as the Skin, the Bottom will be reunited as well as the Outiide, and confequently that Suture may cure a Wound even in the Mufclcs. I thall alledge fo many Inifances of its good Effeas from good Praditioncrs, that Surgeons' will, be forced to revive it. BEVORI Operations of S U R GE RY. 21 13EF FORr RFa dry Suture be made, in any Part wha'rfoever, care ought to be takcn to fiave the Skin in all thofe Places whcre the Plaiflers are like to reach, not only bccaufc the finall!Hir hinders the Plaifters from flicking clofe to the Skin, but alfo becaufe it occafions a great Pain, by hindering the Plaiffers from beingr cafily taken off aftcr the Cure. T HF R arc twlo ways of making that Suture: the one, whcrcin the Opcrator ufes two Plaiffers together with Ligatures, and the other whzcrein he ufes but one Plaifferx without Threads. To put the former into Praalice, the Surgeon cuts two Pieces of ncw Linnen, of a bignef's proportioned to the Depth of the Wound; for the Plaiflcrs inufi be larger or finaller according to that Depth: The Pieces of Linnen having their Selage next to the Wound, mnuff be covered with a Plaitier of Andreas a C'ruce, which is a very good one; and three or four Threads muff be ticd to the Selvage of the Linnen, according to the Length of the Wound. TH E Operator warms thofe Plaiftcrs a little, and applies one of them on each Side, at a Fingcr's Breadth from the Edges of the Wound, that he may the better re-unite it,, and apply upon it the necefflry Remedies. Afterwards he brings the two tips of the Wound together, and -applies upon it a Plaget dipt in an agglutinating Balfam. A Servant keeps the Wounds in that Situation, whilff the Operator fattens the Ends of the two Plaifters with a fingle Knot, and a Loop, which he makes at each Thread. He puts upon each Plaiffer a longitudinal Comprefs, and above thcnm another Cornprefs fplit in the Middle, and a contenvive Bandage. C3 ~THE Z t A Treatffe of the THE very next Day the Surgeon muff examine that Wound; and if the Suture be relaxed, he muft ftraiten it by tying the Threads clofer: But if it be not relaxcd, he only moiftcns the Plaget with fome Drops of the fame Balfam, and applies the fame Comprefies and the fame Bandage. THE fecond way of making that Suture is with a fingle Plaifter without Threads. The Plaifter, as I have juft now laid, muft be proportioned to the Depth of the Wound, that is, this Plaiftcr being as large as the two others together, it muft furround at leaft the two Thirds of the Part. MR. Petit leaves a Hole in the Middle of it, not only that one may fee whether the Wound be well reunited, but alfo that one may apply fome Remedies to it. The Surgeon warms the Plaifter, and prefently applies one of the Ends upon one Side of the Wound, laying on it the Palm of his Hand in order to heat it. Afterwards he re-unites the Wound, and applies the other End of the Plaiftcr upon the oppofite Part. He lays above the Holes of the Plaifer a Plaget dipt in fomc agglutinating Balfam, and then the Compreffes and Bandage, as I have juft now faid. T HE true Suture is further looked upon as fimple, and compounded: the firft is made with Thread and Ncdles Such are the interfeted and twifted. The compounded Sutur.e is that, which befides Tread and Needles, requires alfo fomc other Bodies: Such is the quilled. L As T L Y, the fecond fort of Suture being made without Interfcftions, is like that which the Skinpers make to fow their Skins and therefore it is called Operatios of S U R GE R Y. 13 called the Skinner's Suture: It is ufed in the Wounds of the Intefiins. AMONG the true and incarnating Sutures, the interfcaed is the moft confiderablc. That Suture is proper for a Wound of a fnall Depth, whether it be longitudinal, tranfverfe or triangular, provided it be free from the Obftacles mentioned in the foregoing Chapter. To make the intcrfeded Suture, I fuppofe a Wound crofling the Fore-part of the Thigh, about three Inches long, and penetrating not only into the Tcguments, but alfo about two or three Lines into the Body of the Gracilis. In order, I Lay, to perform this Operation in fuch a Wound, the Surgeon muft firft of all prepare the Apparatus, whicli confifis, befides the ufiial Dreflings, in havingc crooked Needles, which are generally proper for all the Parts, whereas the ftrait ones are only proper for certain Parts, and for Wounds that go no deeper than the Skin; nor are they ufed with the famre Eafe as the crooked ones. Afterwards the Operator pulf have fome even and foft Thread, of a Bigncfs fuitable to the Wound, as well as the Needles, which ought to be of a different Bignefs and Length, according to different Wounds. The Surgeon ufes alfo Threads of a different Bignefs, according to the Rfiffance which the Lips of the Wound can make; and befides waxes them, not only for a greater Safety, but alfo that they may pafs more eafly through the Parts, and left they 3Ifould be imbibed with the Moifinefs, which might occafton an Eryfipelas in the Skin; and not, as forme pretend, left they fhould corrupt, fince after Oany Operations, and after they have been long C4 in 24 A Tieatfe of the in the Wound, they are taken out without - being damaged in the leaft. It is alfo proper that the Surgeon fhould keep the Lips of the Wound fitcady with the Canntla, whilft he makes the Suture, though the Fingers, as far as they can be ufed, are always the moft proper and the fafeft Intruments. THE Apparatus being thus prepared, the Surgeon fhall take care to clear the Wound of all the Clods of Blood, and other extraneous Bodies, that might be in it: Afterwards he mufl bring the Lips of the Wound together, and make a Servant to hold them in that Situation, whilft he takes with the right Hand a Needle, (fuppofing the Wound fuch as I have juft now deferibed it,) threaded with a finall Fillet fuitable to the Depth of the Wound, and more or lefs firong, according to the Refifltance that may be cxpeted from the divided Muifclcs, as I flall fiy hereafter. And then conveying the Point of the Needle about three or four Lines from the Edge of the upper Lip of the Wound, or, to fpeak more properly, of that Part of the Mufcle, which contradts moft; and being in the Middle of the Divifion, he fhall apply the Fingers of his left Hand to fupport the lower Lip much at the fame Diftance, and in the fame Place, and he mhall drive the Needle fo as to pierce in depth a little lower than the Middle of the Divilion, in order to avoid an Abfccfs, taking at the fame Time, and with the fame Stitch, the two Edges of the Wound. The Needle being paffed, the Fillet muft be drawn till what remains of it, does not exceed the Length of five or fix Inches above the upper Lip; and if the Wound is confiderable enough to require three Stitches, they mutt Operations of S R G ER Y. I muff be made at once, and the Thread, or fmall Fillet muft not be cut till the Stitches be made; bccaufc if it be cut after every Stitch, the Patient fancies that the Operation is performed the firft Time the Needle is pafled, and his Fright, as well as his Pain, encreafes when he is pricked a fecond and a third Time. The two other Stitches muff therefore be made all together, on each Side of the foregoing, and with the fame Rules, leaving after every Stitch as much of the Fillet as will be neceffary to tie them, and then they muff be cut in the Middle. BEFORE Mr. Tetit had taught this Method, the Surgeon cut the Thread after every Stitch; which is the Reafon why that Operation was called the interfcecd Suture. I F the Extent of the Divifion does not require three Stitches, the Operator fhall not begin the firft in the Middle, but at fome Diflance from it, and the fecond at the fame Diflance on the other Side, direCing the Puntions fo well, that there be not a greater Diftance between the two Stitches, than from the Stitches to the Extremities. I F the Wound has an Angle, the Surgeon begins with the Angle: If it has two Angles, he begins with the moft folid: Lafftly, if it has many Angles, he muff always begin with them, and always with the moft folid. If the Diftance from one Angle to the other be too great, he muft make a Stitch between both. IF the Wound is like the Figure of a T, or Quadrangular, two Stitches will be fuficient to reunite it, without cutting the Thread' between thofc two Stitches. THE d A Treat~ of the T Hi Operator begins the firft Stitch in the lower Part of one of the Arms of the T or f, and piercing, as I have faid, at the ifame Time the two Lips of the Wound, he draws the Needle through the upper Part of the fame Arm, and at the fame Diflance. Afterwards laying two Fingers of the left Hand upon the Sides of the Fillet, which comes out above the upper Lip, he draws it gently till what remains of it be not above four or five Inches long under the lower Lip; and without quitting the Needle, he paffes it through the other Arm with the f ame Caution, (only with this Diffeience, that he begins to pierce the Skin above the upper Lip3;) and then he makes fome Knots, and a Loop upon the Body of the T or Crofs, which does perfectly re-unite that Wound, &c. IF thofe two Stitches, which are in the Center of the Divifton; do not well reunite the Extremities, a Stitch may be made in them. THE Surgeon having carefully confidered all the Circumfitances I have juft now mentioned, mnufti take the End of the Fillet hanging under the lower Lip, (I mean that which is in the Middle, if there are three Stitches,) and bring it over the upper Lip to tie it with the other End of the ifame Thread. He makes a fingle Knot, that he may the more eafily loofen it, in cafe any Accident fhould happen. -A r, thofe, who have writ concerning chirurgical Ope:rtions, advife to lay a fmall Comprci upon thCt firft Knot; *but Mr. Thibault, fworn Surgccon w Prss, and Major of the Hotel-'Diez by Rc 1: - her chufes to ufe a finall Roll of waxed T1. 11., ot only becaufe it is more conVCic, Ilt Operatlos of S u R G R O.. 27 27~ vcnicnt and more folid, but alfo becaufe it Will not be imbibcd \vith the Matters, that continually come out of the Wound. By which Means one may prevent an Eryfipelas, which frequently happenis in the Skin, when Linnen Compreffes arc made ufe of: This is no firall Advantage, fince an Inflammation does very much hinder the Re-union of XVounds. Which is alfo the Reafon why the Threads are tied over the uppcr Lip of the Wound, as bcincr the moft folid Place, and Iifch as isleaR cxpofed to the dit'chargec of the Wound. THE Operator makes a fingle Knot upon the Roll of waxed Taffcty, and a Loop above the fecond Knot. He muft obferve the fame Method in Relation to the other Threads, taking care not to tic them too firait in the Beginning: This lafi Circumfiance ought to be gcncrally obfervcd in all Suturcs. AFTERWARDS the Surgeon muff drefs the outfide of the Wound. He muft firfi of all lay upon thý- Knots a fmnall double Comprefs made ofLinnen, and then upon the whole Extent of the Wound a Placgrc, dipt in the fame Balfam, which has already been introduced into the Wound,. after having takcn out the Clods of Blood: Lafily, he muff put over it one or two Compreffes according to the different Parts; the whole being fhupported by a Bandage only contentive, Vhich confcq ucntly ought not to be tight. I do not ufe Plaiffers, becaufe they hinder thc purulent Matters from coming out of the Wound, or becaufe by letting them ffagnate upon it, they heat the Skin, &c. and prevent Tranfoiration. Lafilv, after having performed the Operation, and applied the Drefling; the woundcd part mutl be 28 A Treat;fe of the be placed in a proper Situation, and the Patient blooded, ifneceffary. The Surgeon muft prefcribe Glifters, when the Patient is coffive, and order him to keep himfelf quiet, which very much contributes to help Nature in her Operations. THE Operator does commonly leave that Drefling two whole Days without taking it off, unlcfs fomc Accident happens, as fhall be faid hereafter; and then he gently takes off the Roller, and con - prefles, and if they flick a little, he moiftens them with warm Wine: lattly, he obferves whether the Plaget flicks to the Wound, whether the Wound be inflamed, whether the Patient felt a great Pain, &cr. and if none of thofe ill Prefages appear, he pours fome Drops of the fame Balfam upon the Plaget, puts on again the Compreffes and Bandage for two Days more; and fuch Wounds are generally reunited, or in a fair way to be fo, after fome Dreilings repeated in the fame manner, unlefs any extraordinary Accident fhould happen. TH E R E is ftill another fort of Wound, which requires the intcrfcted Suture. I place under that kind of Solution of Continuity the Wounds with hanging Lips, which are generally occafion'd by cutting or bruifing Inftruments. The former may hurt all the parts of the Body; but it feems the latter cannot make fuch a Wound as we here fuppofe, but when the Blow falls flanting; which frequently happens upon the Head. THOUGH the Wounds, occaflon'd by bruifing Inftruments, require none of thofe Operations which we have already mentioned, viz. the Situation, the Bandage, and the Sutures; yet becaufe they are not bruifed, Operations Of SURGER Y. 29, brifed., I fhall not fcruplc, in imitation of the bef Pratitioncrs, to make Stitches in them. WHEREFORE let us fuppofe a Wound in the fore and upper part of the coronal Bone, which has a hanging quadrangular Lip, and the two lowcr Angics whcrcof flick to the Skin. In order to cure that Wo-und, the Surgeon mull wafh it with warm Wine, raife the Lip fpecdily, and make it level with the other Parts. He muff make two Stitches, one in each Angle, remembring afl the Circumftances above mentioned: But in fuch Wounds as this, he ought particularly to dirca his Needle in fuch a manner, that the firfi Stitch, which mull be in one of the Angles of the Lip, may take in its whole rhickicf-; but the fecond, which Ihall be in that part of the Head that is not loofe, Thall only pierce the Skin to avoid the Aponcurofis of the frontal and occipitalMufclcs, and to prevent by that means hlofe accidents, which frequently happen, as, Mr. Arnaud obferv'd in a Perfon, to whom that Suture 'was made. The Needle reaching beyond the hairy Skin, pricked the Aponeurofis of thofe Mufcles the Head fwellcd foon after, and was inflamed, e1pccially before and behind: He cut the Suture; and two Hours after, all the Symptoms vanith'd. STHE EOperator, without quitting the Needle, mnlakes the fecond Stitch in the other Angle of the ýWound, obferving the fame Circumifances: But becaufe in that fort of Wounds the Skin of the Sides contra.6s it felf, efpecially that which has a hanging triangular Lip, it is not improper to make fome Stitches, which mull not be tied ftrait before' the Suppuration be well formed, to avoid an Eryfipclas, which molt commonly happens, and hinders 30 A 7 featf of the dcvs more than any thing elfe the Rc-union of the Wound. THE Operation being pefform'd, the next thing is the Drefling, which muft 6nly confift in pouring feveral Drops of fome unitifig Balfam upon the Circumference of the Wound, and then applying a Plaget dipt in the fame Balfam, of covered with a good Digeftive: That Plaget muff teach a Finger's breadth beyond the Circumference of th& Wound. WVHEN the Surgeon applies the Plaget upon this fort of Wounds, he muft firft of all lay the lower part of it a Finger's breadth undei the lower part of the Wound, and by a fucceifive Application of the remainder of the Plaget, the Lip is brought towards the tipper part. Ihe ficame Caution ought to be ufed with refpe&t to Plaifters, if any are laid on, and int relation to the Compreffes, the Difpofition whereof depends upon the Sargeonys Skill. The Bandage muft be only contentive, and furround the Head without compreffing the Ears; and the Couvre-chcf, which I ifhall deferibe elfewhere, muf be laid over it. PHLEBOTOMY Will be of good ufe to prevent an inflaimmation. The Patient muff not be allowed to fpeak, becaufe the Motion of the Jaw and Tcmporal Mufcle give Concuflions to the Woundi from whence it follows, that he muft have no other Food for three or four Days but Broth very nourifhing, which he fhall take with an open and flatted Spoon. That time is fufficient to reunite the Wound, or wvill put it in a good way of being foon reunited. WHEN the Surgeon takes off the drefling of that fort of Wounds, he muff, as he did in applying it, cnsdce Operatlons of S U- R GER Y. 3I endeavour to bring the hanging Lip near the upper part of the Divifion 5 and therefore a prudent Operator ought to take off the Drefling by its lower part; and with this Caution, the Lip feems to be brought nearer the Parts to which it was continuous before the Wound. The fame Caution ought to be ufed with rcfpect to all other Sutures, that the Surgeon may not run the hazard of renewing a Wound, which he endeavours to cure. I attended once a Wound with a hanging Lip of a quadrangular Figure; but it was quite different from the Wound, which I have juff now defcribed. It happened to a Youth of fixteen Years of Age, who being kicked by a Horfe in the lower part of the Chin, had the whole kuadratus divided from the Jaw-Bone, and the hanging Lip, which was at leaft every way two Fingers broad, fiuck only to the lower Lip. That Wound afforded a great deal of Blood, a fmall part of which, as it coagulated, fluck to all the Edges of the Wound j which preferved from the Injuries of the Air the Jaw-Bone, that was partly denuded. A young Surgeon had a mind to cut off the hanging Lip, which did, as it were, jut out; but a Perfon very zealous for the Patient fent for me. I confidcr'd the Wound, and without blaming that young Surgeon, I faid it might be cured more fpeedily, and with greater Safety and lcfs Deformity without cutting off the Lip. IN the firft place, I moiltened the Wound with a fine Rag dipped in warm Wine, and endeavoured to take off all the coagulated Blood with all poflible Dexterity and Speed. Afterwards I laid the hanging Lip level with the other Parts, and m'ade in the lower part of the Wound two Stitches, one 3 7 A Treatf/e of the one in each Angle. Having well reunited that Divifton, I poured upon the Circumference of the Wound fome Drops of the Balfanm of the Commandeur de Parne, and covered the whole with a Plaget dipt in warm Wine, and armed with a Mixture of Terebinthine and the fame Balfam. WHEREAS in the Wound of the Head with hanging Lips, abovementioned, Surgeons ufually begin with applying the Dreffing in the lower part, I began with the upper part, and dire&ed with the Finger the Plaget towards the lower part, in order to facilitate the Defcent of the loofe piece. I put on a Comprefs dipt in warm Wine, and flit in the middle, and above it a Bandage called the Sling, the upper Head of which I applied firft to the lower part of the Chin. I took care to tie it ftrair, becaufe the Reunion did chiefly depend upon it; but I faftened the lower Head loofely, to prevent the raifing of the hanging Lip, and to facilitate the Difcharge of the Matters. I blooded the Patient immediately, forbad him to fpeak, and ordered thofe who tended him, to give him a glifter in the Evening, and to nourifh him only with Broth taken every two Hours with an open Spoon. The third Day I took off the Dreffing, removing every Piece firft by its upper part, to avoid giving any Motion to the loofe Piece, and to facilitate the Reunion of it. I found the Wound fo well reunited, that I refolved to cut the Stitches. Afterwards I laid again a Plaget dipt only in the Commandeur's Balfam, and the reft of the Af4 -paratus, as before, which was left on three Days longer fo that on the feventh Day the Wound was fo well cured, that the Scar could zot be pereived Operations of SUR GER Y. 33 ceived but by thofe, who were ivery near the Pa. tient. I ihould now, according to the Order of nimy Difcourfe, treat of the twitted Suture; but becaife& it is ufually praftifed for an Operation called the Hare-Lip, I refer it to the Operations telating td the Head, and fhall here fpeak of the compounded Suture, which, as I have faid, diffeis from the fui.t ple one, becaufe, in order to make it, fotihethinii more is requifite than Thread and Needles. WE have reckon'd among thefe forts of 0prations the quilled Suture: It is iwhoally rejceIed in modern Books, and condemn'd as being ufelefs a d too cruel: But the learned Surgceons, whofe Names.re an Orn'ament to this Treatife, fay that the quilled Suture is the fafeft way of reuniting thofe Wounds, wherein the Mufcles are dccplV cut, and the Parts naturally difpofed to recede from each other, either by their own Weight, the Elafticity of their Fibres, or the cOntinual Motion to which they-are liable, as it niay happent in the deep Wounds of the Glutei, and of the Mufeles of the Thighs, Legs, and Arms, and in the great Wounds of the Abdomen. FOR an initance of the quilled Sutuie, let us fuppofe again a Wound in the forepart of the Thigh, but fuch as is fiVe or fix Inches loug-, atid feems to cut a confiderable part of the Gracitis. THE fiti thing a Surgeon ought to do towards the Cure of this fort of Wound, is, as in all others, to take off the grtumdous Blood, which hinders the Reunion. Afterwards he muff tlace the Part in a good Situation; and the moft proper in this Cafe is to bend the Thigh, in order to bring togcther the D Lips 3 4 A Teatife of the Lips of the Wound, that are afundcr, by the natural Spring of the divided Fibers, which fhlrink, as it were, into thcmfclves. AFTERWARDS the Operator muff take a crooked Needlc of a proportioned Bignefs, and fuch as contains the requifite Conditions, which I fhall defcribe at the End of this Treatife, when I come to fpeak of all the Inftruments proper for a Surgeon. That Needle ought to have a particular Thread, and not a Lace; or a Fillet woven with Thread, which has been ufed hitherto; becaufe the Lace being round, acts only upon one Point, and confequently cuts, cfpecially when there happens an Inflammation, which is an ufual thing. A Fillet woven with Thread is liable to much the the fame Inconveniencies, by reafon of its two Edgings, which cut the Parts. Thofe Fillets are alfo very troublefome, becaufe in a twifted Suture four Ends of them muff be pafled through every Stitch; which gives the Surgeon a great deal of Trouble, pains very much the Patient, and occa'ions an Inflammation in the Wound. MR. Petit ufcs with lefs Trouble, fix, eight or ten white Hemp-threads, laid together one by another, and waxed all at once. By that Means hec 'has a Fillet, the Edges whereof are free from the Inconveniencics attending common Fillets: It is flat, even, and foft, and ucful in feveral other ReIpc~s, as I am going to fhew. A S UR GEON muft have many fuch Fillets of different Breadths, that is, made up of more or fewer Threads, according as he defircs they fhould be fironger and broader, always taking care that a double Fillet be not fo big as the Needle,. that he Operatious of SUR GERG Y 35 he may the more cafily pafs it through the Parti But the Thread ought to be diffcrent, according to the Difference of Wounds; for in the deep Wounds of the great Mlufclcs Surgeons ufe a fort of Thread, called Bretagne-thread, and known ini this Province by the Name of twifted Thread. As for Wounds not very deep, or that are in tender Parts, they ufZe a white Thread, which Seamfireifcs call `l d' 1 pinzay. BE F 0 1 E the Needle be thruft into the Woutnd; a prudent Surgeon ought to put his Finger in the whole Extent of the DiVifion, in ordct to feel whether there are any Arteries crofing the Mufdces, that he may avoid to open them wheni he makes the Suture. This Caution is ufed by Mr. Arnaud; and ought to be ufed in all the tranverfe and deep Wounds of the great Mufcles, that require a Suture. AL L thofe Circumilances being duly obferved) what remains is to perform the Operation in the following Manner. Thie Surgeon muff pierce With a Needle, and all at once, the two Lips of the Wound, taking more of the Skin tharrn of the Fat, becaufe th e Skin contraats afterwards by itsq Spring, and the Fat being re-united, the,Vound gapes, and the Scar is deformed notwithtanding the Suture. THE Operator, muA begin with the Middle of the Wound, if it be large enough to rcquire thred Stitches, and with thre Lip anfvweriing the Origin of the -Mufele, becaufe it contracts r'off. Aftcrwards he drives the Needle pretty far into the Parts, that is, about two Thiids of the Depth of the W ound;, and even deeper. For Iniftance, if i was Dzabout 3 6 A Treatife of the about one Inch and half deep, the Necedle fhould be driven into it to the Depth of one Inch, and more, that the Surgeon may bi-ing the Bottom of the Wound together, and not fuffer one Drop of Blood to remain in it, becaufe that Blood, being cut of the Courfe of the Circulation, would ferment, and quickly occafion an Abfcectfs THAT Stitch being made, the Surgeon mufft make two more, one on each Side of the firfit, without quitting the Needle, or cutting the Fillet, before all the Stitches are made. However they ought not to penetrate fo far into the Part, becaufe the Extremities of the Wound are never fo deep as the Middle. THESE Rules appear to me fufficient, becaufe by their Means the Bottom of the Wound will be perfcdly united, as well as the Out-fide. On the contrary, if the Needles were driven into the Bottom of the Wound, or beyond it, as fome would have it, the Out-Efde of the Wound would remain gaping, and the Fibers being afunder, their Extention would require a longer Time, and the Scar would be more deformed. AN D if the Needles were only driven fuperficially, cir at moft into the Middle of the Divifion, according to the Opinion of other Surgeons, there would remain a Bottom, which would quickly be attended with an Abfccfs, that might even occafion a Sinrls. I T being very difficult to pierce the Skin with Needles, efpecially that of the Abdomen and deep Wounds, fbme advife the Ufe of a Port-Nedle; but then it muff be very finall. Operatiols of SURGERY. 37 Mr. Petit has invented an Infirument like a Ring, in the outward Circumference of which there is a finall Peg, about which a fmall Pivot tuirns, madc hollow like a Funnel to put in the Head of a Nccdle. That little Pivot is riveted with the Ring by means of the Peg, fo that it turns like the Nave about an Axle-tree. This Infirument is very convenient, and proper in moft Suturcs, without giving the Surgeon any trouble. No w the Operator muff apply the Infiruments, to make the compounded Suture. They are called Pcgs, and diffcrently made,according to moft Books. Some make ufe of a Roll of Linnen; but thofe Pegs being imbibed with the Matters continually ifliiing from the Wound, occafton an Eryfipelas, whcli obliges the Surgeon to cut the Suture. Others, to prevenct this Accident, ufe a waxed and rolled Taffety, which indeed will not be imbibed with the Matters, but it preffcs the Wound only in the place where the Stitches are; which occafions flill fome Vacuities between every Stitch. Lafly, Others make ufe of more folid Bodies, fuch as Quills, &c.; but thofe Infiruments being applied upon fuch a round part as the Thigh, wound the Extremities, and bruife the Middle. A ~L thofe Inconveniencies moved Mr. Arnaud to make ufe of two Pieces of very fmall WaxcanIcdles, which ada'pting themfelves to the Figure of the Part, may aloib, by their folidity, anCtwcr the Surgeon's intention. But he finds another inconveniency in it; for thofe finall Wax-candles growing hot, melt, and the Thread he makes ufe of, gets into them, and loofens the Suture. To prevent this Accident, he rolls, about each piece of a Wax0D 3candlec 8 A TTreat;fe of the tandie, a fmall piece of waxed Taffcty, which he faflens with the Plaifkr of Andreas ai Cruce. That finall Roll is foft, and adapts it felf to the Figure of the Part. It cannot be imbibed with the Matters iffhing from the Wound. It compreffes the Wound equally in all its Parts, and does not relax. Having thus fitted two fmall Pegs, the Surgeon muft makc a Knot at each end of the Fillet, which recches beyond the upper Lip of the Wound, and divide the Threads of which that Fillet is compofed, between the Knot and the Wound; whereby Loops are made, into which the Surgeon paffcs one of the Pegs; and then putting two Fingers upon the lower Lip, one on each Side of every Stitch, lie draws all the Fillets one after another, beginning with the middle one, that he may perfedly bring together the divided Parts. Afterwards he divides each Fillet of the lower Liv into three, two of which will ferve to tie the fecond Peg: He makes a fingle Knot with the middle Fillet upon the Peg, and then brings the Lips of the Wound together with all poflible care and dexterity. He always makes fingle Knots in the other Fillet, remcmbring the general Obfervation about all Sutures, viz. that they muff not be tied too firait in the beginning, Laftly, he makes Loops abovc thofe Knots. In the next place, the Surgeon dreffics the Outfide of the Wound, which does not require a great Apparatus. Mr. 'Duverney, Dotor of Phyfick, Profeflbor of Anatomy and Surgery in the King's Garden, and Member of the Royal Academy of Skiences, advifes to put upon it a Plaget, dipt in the Balfam of Fioraventi, or Copahu, or in the Effnce of Operations of SURGER Y. 39 of Terebenthine. I fhould think the Commandeur's Balfan would be of very great ufe upon this Occafion, becaufe it confifts ofoily, balfamick and volatil Particles; and becaufe as it dries upon a Wound, it forms a kind of Cruft, which keeps the Air from getting into it, and by that means procures a fpcedy re union. TH E Stitches being pretty deep, the external Parts fvcll a little; and therefore it is not improper 'to tic above the Plaget the third Thread of each Fillet with its Antagonift, in order to comprefs the Outfide of the Wound, taking care however not to tie it too ftrait. THE Surgeon puts above that Drdfling foime Compreffis dipt in a proper Liquor, and fupports the whole with fome Convolutions, which tend, as well as the Suture, to keep the two Lips of the Wound together: he begins that Bandage with two or three Circulars, fomewhat below the under Lip of the Wound, and goes on upon the upper One by making Turn-over's oppofite to the middle of the upper Lip, to bring the two Lips near each otiher. Afterwards he defcends behind the Thigh, and makes a Circular above the lower Lip; fo that, according to this Defcription, the Turnings which are in the Part oppofite to the Wound, ought almoft to crofs one another. TH IS being done, the Part muft be placed in a proper Situation; and the Surgeon does not neglcft to ufe the general Remedies, which he may think necefhfary. HE mult, in the firif Days, take off the Roller, and the Compreffes, in order to examine the Circumferencc of the Wound; and if the Skin be in a D 4. good 40 A Treatfie of the good State, if the Patient does not feel too great a Pain, or a confidcrable Pulfation at the Bottom of the Wound, the Surgeon does commonly leave on that Drefling fix or feven Days, more or lefs according to the good Conftitution of the Patient, in fhort, till it appears that the Wound is well reunited. I F the Surgeon perceives in the firft Days, that the Suture is too loofe, he may ftraiten it a little, and loofcn it, if it be too ftrait. LAST L Y, if the Lips of the Wound appear fomewhat bruifed, a gentle Suppuration for four or five Days, leffening the Bulk and Tenfion of thofe Lips, will prevent an EryfSpelas: This may be cffc&tcd by ufing digeftive Ointments, and Arceus's Balfam. W E frequently fee after thefe Sorts of Operations, that there happens an Itching in the Skin, a great Pain in the whole Member, an Eryfipelas, a confiderable Inflammation, a Fever, and a 'Delirium. The Surgeon muft not then be frighted, but only untie the Loops, that are upon every Stitch, loofen the Knots, put upon the Wound a Plaget, armed with a Balfam that will excite a gentle Suppuration, fuch as Arcxus's Balfam, or fome other, according to the Experience of the Surgeon, and blood the Patient plentifully, without negleting Glifters, Chicken-broth, and diluting Diet-drinks, UC. THO E fad Accidents being over, the Stitches muff be ftraitened hy Degrees, that is, about one Line every Day, and the Wound muft be drefl~d, as I have already laid. ON Operations of S u R GER Y. 41 O N the contrary, if thofe Accidents continue, and even encreaie, fuch arthe Tenfion of the Part, and the Inflammation, thcn,"' ithout any Hefita-. tion, the Sutures ought to be cut, and the Wound drcflfd as ufually. LAST L Y, if the Induffry of the Operator has been attcnded with a good Succefs, and'the.Wound is re-united, his Prudence and Dexterity mutt alfo enable him to cut the Stitches of the Suture. His Prudence will teach him when 'tis time to cut them. He will know it, when he fees the Th-read or the Fillet very loofe in the Divifions made by the Needle. And if in this Cafe the Re-union is not perfccated, the Suture is no longer of any Ufe. A further Proof of a perfe& Re-union is, when the Scar appears like a flcfhy Line, fomewhat red, a littlec raifed, even, and without Pain. TH E Dexterity of the Surgeon will teach him to cut the Sutures fafely, and to take off the Threads; which he does, if it be the interfeated Suture, by putting a imall Probe under the Thread, with the help of which he cuts it near the Knot wiith the Point of the Sciffars. Afterwards he puts his Fingers upon the lower Lip on each Side of the Stitch, and with the other Hand he draws the Thread by the Knot; and with this Method he fafely takes off the feveral Stitches, without running the Hazard of renewing the Wound. T H E next thing is to cure the fminall Divifions made by the Needle, which may be done in a littie Time, by pouring upon them fome Drops of the Commandeur's Balfam, and laying over them a Comprcfs, dipt in warm Wine. 41 A Treatfe of the IP the Accidents are fuch, that the Surgeon thinks himlelf obligcdto cut the Sutures, in or. der to avoid a greater'Diforder, he muff, as I have already faid, drcfs the Wound in the fame Manner as Wounds without Suture; which gives me Occafion to fet down many general Precepts propofed by the learned Mr. IDuverney. Precepts neceffary fbr the well drefing of Wounds. I. Precept. One muft avoid the Method of fome Surgeons, who probe Wounds at every Drefling, and thereby make fmall Wounds every time they.ufe a Probe, by tearing or comprcfling the Extremities of the fmall Tubes, which arc very foft and tender. II. Precept. Great Incifions ought not to be made without Neceffity, for fear of encrcafing the Wound. The Surgeon ought to make them only, when tis neccffary to evacuate the purulent Matter, or to take out fome extraneous Bodies, or fome fragments of Bones broken or carious. III. Precept. The Operator muff drefs the Wound foftly, and without exciting any Pain, forbearing to introduce into the Wound Dozels, Tents, and other dilating Bodies, which ftopping the fmall Tubes occafion Inflammations. It plainly appears that all thofe things are contrary to Nature; for when a Wound thus filled is uncovered, the Dozels and Tents come out of it all at once. IV. Precept. Operations of SURGERY. 43 IV. Precept. A Tent is abiolutely nectffary after the Ga/irorhaphia, when the Surgeop has made the Ligature of the Epiploon, or the Suture of the Inteflin, or the Operation of the Bubonocele, or in the dreffling of a Fi/lula: But Tents ought not to be ufed, when they appear needlefs, efipecially in the Wounds of the Joints. I fhall fhew in the next Chapter, that this Pre' cept ought to be obferved only in fome Fi//ula's, and that the ufe of Tents is repugnant to Nature and the Defign of the Surgeon. V. Precept. The Dreflings ought to be fpeedy, in order to avoid the Impreflion of the Air, which coagulates the Juices and the Blood of the Extremities of the Fibers, and of the fmall Veffels, and thereby occafions feveral Obftruftions attended with Inflammations, and confequently with great Pains, and even with a Fever. VI. Precept. Wounds ought to be dreffed but feldom, that Nature may have Time to produce the fmall flethy, bony, or tendinous Papille, which ought to fill up the Wound. One muft drefs at leaft twice a day thofe Wounds, that fuppurate much, cfpecially in Summer, to avoid the Corruption, a Gangrene, &c. VII. PreCpt. The Wound ought to be gently wiped, for fear of taking away the nutritive juice, which muft repair the loft Subftance, and occaftoning a Pain, by irritating the nervous Fibers of the Wound. VIII. Precept. 44 A Treatife of the VIIl'"Precept. Rottening Ointments. ought to be ufed as little as poflible. IX. TPrecept. Fat and oily Remedies ought not to be ufed in thofe 'Wounds, wherein there is an Inflammation or an Eryfipclas, bccaufe locking up the Pores, they prevent Tranfpiration, and encrcacf the Difeafe. X. Precept. Spirituous Remedies ought to be laid afide, when the Suppuration is in a good way, becaufe they harden the Extremities of the fmall Vcfcels, and occafion a reflux of Matter. On the contrary, gentle and balfamick Remedies ought to be ufcd, fuch as the Balfams of Fioraventi, and Copahu, the Effence of Terebenthine, &c. XI. Precept. Inje&ions ought never to be ufed but in deep Ulcers, wherein there is a Sinlw, into which the Medicaments cannot be conveyed; and when they are ufed, they muff be pumped immediately. Wherefore I propofe a Pipe ending like a Nipple, capable of being exadly applied upon the Wound, adapting to the broad End of it a Syringe; and with the help of its Embolus all the Juices, which happen to be extravafated in the Wound, ought to be extraded. WHAT is called dreffing by charm, is what a fucking Man does by drawing and pumping the Blood and the Lymph; and then he puts a good Comprefs upon the Wound, and leaves it on five or fix Days without taking it off Some add Words Operations of SURG E.RY. 4T Words tO the Suation; but it is only to impofe upon the People. It may be obferved by the by, that this Pradice does not fucceed but when there are no large Veffels opened, or when the Bones are not fradured. XII. Rrecept. One ought to prevent or deflroy the Callofity, which fhuts up the Extremities of the Tubes, and keeps them from pouring the nutritive Juice to repair the loft Subitance. XIII. Precept. A Seton ought to be ufed, whenii the Wound is quite thorough, to convey the Remcdy within the Wound, and hinder the Lips from being re-united fooncr than the Bottom. XIV. Precept. The Compreffes ought to be imbibed with ibfme warm Liquor, litch as Wine, or fome Fomentation, when the Drefing is to be taken off, that they may cafily be loofenlcd, and no Divulfion be made in the Fibers of the Wound. XV. Precept. Plaifters ought to be ufed as littie as pofible, becaufe they clofe the Lips of the Wound, and hinder Tranfpiration. XVI. fPrecept. Wounds ought not to be rolled ftrait, fince the Bandage is only defigned to keep on the Remedies, (excepting however longitudinal Wounds, to bring remote Lips together;) for Comprflion hinders the Circulation. XVII. Precept. Lafily, the Surgeon ought to ufe evacuating, and knitive Remedies, fi.ch as Vhjlebotomy, 46 A Treatife of the Phlebotomy, Glifters, Diet-Drinks, Emulifons, &c. Vulnerarics are proper, when the Blood is thick and clogged with a Chyle of the fame Nature; but then there ought to be no Inflammation in the Wound. They are alfo proper in the Wounds of the Vticera. The beft way of giving them is to make a thin Decodtion of vulnerary Plants, and to put a fpoonful in each Glafs of the Patient's ufual Drink. I N fome cafes the purulent Matters return into3 the Blood, without occafioning any Diforder in it; but fometimes they are the Caufe of very fad Accidents. IN the firft Cafe, the purulent Matter having a good Confiftence, remains in the Blood, and is evacuated by Stool and Urine; for it ought to be known and we are fure of it by Experience, that Pus is only pernicious accidentally, and that when it is well tempered, foft and balfamick, it cannot occafion any Symptom by mixing with the Mafs of the Blood; but when it is ill-prcpated, it excites by its fharpnefs and bad Quality irregular Shiverings, a Fever, and extraordinary Pains. I T has been obferved that after fome Wounds, not only in the Head, but alfo' in all the other parts, an Abfccfs was formed in the Lungs and the Liver, by the reflux of the purulent Matter into the Mais of the Blood. If the Matter is more apt to flop in thofe Vifcera than in other parts, 'tis bccaufe they axe fuller of Veins. ONE may know that the Matters are gathering in the Liver, and occafion many fmall AbfccflTs in it, by the Pain which the Patient feels M Operations of SURGR GER'Y. 47 in that Part at the time of the fhivering, and in the Lungs by a Stitch in the Side, and a very great OpprefiTton. T IOS E fad Symptoms happen by the Patient's Fault, and the Surgeon's Ignorance. The fick Perfon contributes to them by his unruly Paffions, an ill Courfe of Diet, and immoderate watching; and the Surgeon by his ill drefling, by filling the Wound, expofing it to the Air, wiping it too carefully, or ufing fpirituous Remedies;when the Suppuration is laudable: All thofe things make the Matters purulent, and carry 'em back into the Mafs of the Blood; which may be known by a dry, blackifh, livid, and flinking Wound. In thisCafe, the Surgeon ought to take another Courfe: He mtift ufe, for a Topick proper to reftore the Suppuration, fome foft and balfamic Remedies, fuch as thofe which I have already mentioned more than once; and the Patient muff take inwardly Cordials, Vulneraries, I'ebrifuges, Diuretics, or Diaphoretics, according to the Exigency of the Cafe. L A.sTL Y, if the nutritious Juices are acrimonious and falt, the Wound cannot be clofed up which ought to be prevented by Purgatives, and by lenitive and incraffating Remedies. WHEN Hippocrates faid that Wounds of a round Figure could never or hardly be cured, he meant thofe that have callous Edges; for we fee that the Extirpation of the Cancer, Amputations, and other Wounds are cafily cured. T o put an end of what concerns the Cure of Wounds in general, it ought to be obferved, that the Evennefs and Infenfibility of a Scar, are a Sign that the Wound is well cured 5 becaufe 'tis a Proof that 48 A Treatife of the that there are no extraneous Bodies under the Scar. WHEN the Pain is quite over, and the Part moves freely, 'tis alfo a Sigh of a perfca Cure. CHAP. IV. Of the Gafirorhaphy. T O follow the anatomical Order, which conim Tj monly begins with the Parts of the Abdomen, becaufe they are more liable to Corruption, I fhall now treat of the Operations performed in that part of the Body. THOSE Operations are of feveral forts, and performed to cure very different Difeafes, fuch as Iimple or complicated Wounds, Tumors of different kinds, and which require different Operations, iflula's, and Abfceffes. H A VING named Wounds before the other Accidents, I fhall in the firft place difcourfe of the Gaf/rorhaphy, which is the Operation proper for them. That Word is derived from two Greek Words, viz. kP, which fignifies the Belly, and Fpa, which-fignifics a Suture or Seam. Wherefore the Gaflrorhaphy cannot be better defined, than by faying, that it is a Suture made in the Belly, to prevent the floating parts of that Cavity from coming out, whether they have or have not been redcced, provided the Wound be large enough to require a Suture. A M o N G the Wounds incident to the Abdomen, fome are fimple, and others complicated. All Sthofc 4""E Operat;on of SURGERY. 4 thofe who have tieated of chirurgical Operations, reckon among the fi mbple Wounds of the Abdomen, thofe which do not penctrate into the Cavi. ty: On the contrary, complicated Wounds, itn th6 Opinion of thofe Authors, are thofe, that panetrate into the Cavity. As for me, I underfland by fimple Wounds nily thofe, that are attended with no Accidenf * for there are Wounds, which do not pehft5ate into the Abdomen, and yet are veiy inuth complicated; fuch as thofe, which atfeta the RECTUS Abdomints, and frequently occafton an Abfcefs between it and its Aponeurofs. This fort of Wounds, or to fpeak more properly, the Accidents that follow them, require from A Surgeon a great Knowledge of the StruCture of thofe Parts, that he miay well direft the neccfltry Inciftons. A ND though the outward Memnbrane of the Sheath be the only Part glanced upon by the Point of fome Inflirument, I am perfuaded therd will be fome Inflamniations in it, which rnay be attended with a Gangrene, whereof thofe membranous and tenidinous Parts are vefy ftufceptible, unlefs the Surgeon fpeedily unbridles and relaxes the Mufcle with Incifions every way. Wherefore the Cure of this fort of Wounds requires a mtich d i eater Care and Attention than that of the rnere Diviflions of the other Parts. B ESIDE ES, fome Wounds, fihodgih penetrating into the Cavity of the Abdomen, are neverthelefs Very fimple, fiuch as thofe that are occafiobicd by fome Thrufls with a Sword, and by fome Balls that have been known to pafs throigh the Body Without oCcaftionihg any fad Accident. I have E frequently 5~ A Tieatife of the frequently heard it affirmed by the moft expert Surgeons of this City, and I was a Witncfs of fuch Wounds about eight or nine Years ago, being one of the Surgeons on Board the Count of Touloufe, a Privateer, commanded by Mr. de la H[unaudiere Nouail. We had in an Engagement with an EngIjfh Ship a confiderable Number of wounded Men, among whom many Seamen received fcveral Balls through the Belly and Breaft; and in lefs than three Weeks, they were cured without any Accident, by Mr. de la Motte Banos, Surgeon-Major, under whom I was. I F all the Wounds of the Abdomen were as lucky as thot juit now mentioned, Men would not be fb frequently expofed to the Hazard of lofing their Lives, or fuffering great Indifpofitions: But we know by a great Number of Obfcrvations, that molt W\ounds penetrating into the Abdomen are attended with Symptoms generally occafion'd by the Wound of fome Vifcus contained in that Cavity, or by an Extravafation of Blood or Matter. ANA TOM Y, confirm'd by daily Experience, fhews that penetrating Wounds of the Breaft with an Effufion, may be cured by a counter-opening, which we call the Operation of the Empyema; becaufe the Blood or 'Pus, remaining upon the Diaphragm, may be evacuated by that counteropening. It is not fo in the Abdomen; and the moft celebrated Prafitioncrs have not yet inforj.med us, that they have found out the way of extrading, by a counter-opening, the Blood or Pus lying in that Cavity: And confidering the different Structure of that Capacity, and the difmal Symptoms Operations of S V R G R Y. 51 Symptoms attending thofe Wounds, a Surgeon muft needs form a very doubtful Prognoftick of them; becaufe generally about the feventh or eighth Day, and fometimes fooner, they are attended with a Fever, an Inflammation, intolerable Pains, Convulfions, a Delirium, and many other fad Accidents, which mofft times end only with the Life. THOS E Accidents, though very difmal, are not the only ones, that happen in the Wounds of the Abdomen: All the Vifcera contained in it may be hurt by the Inftrument, which is the Caufe of that Divifion and according to the Part that is hurt, the Surgeon ought to draw his InduCtions, either for his Prognoftick, or to make his Report to the Judges, or to take a right Method for the dreffing of the Wound. W H E N ome of the floating Parts of the Abdomen do not come out through the Wound, the Probe fhews whether it penetrates and by examining the Inftrument, which made the Wound, either from the Account of the wounded Perfon, or of thofe that were prefent, or by the Sight of it, one may judge of the Nature of the Wound by Anticipation. TH E anatomical Divifions of the Abdomen into Regions, difcover to us very nearly the different Parts contained under each particular Region: But in order to prognofticate more fafely, the Patient muff further be asked, what Situation or Attitude he was in, when he receiv'd the Wound. T HE different Seftions made by Mr. Duverney upon the Abdomen of feveral Perfons, either in a perpendicular or oblique Situation, have flhewn us demonftratively, that the greateft part of the J/2fcera ** Ez of z A Treatife of the of the Abdomen altered their Situation in thofe different Attitudes. Mr. Winflow, Dodor-Regent of the Faculty of Phyfick at Paris, and a famous Anatomift of the Royal Academy of Sciences, has flcwn us, as it were palpably, how much the Liver reaches beyond the falfe Ribs in a perpendicular Situation, efpecially when a Man has been a long time without eating and that this ViYcus being no longer fupported by the Inteftins, comes down fo low, that carrying the Diaphragm along with it, the Vulgar fays upon that Occafion, that their Stomach draws. Mr. Lapeyronie, Councellor, firft Surgeon to the King, admitted by Revcrfion, and Demonftrator of Anatomy and Surgery in the Royal Garden, made an Obfervation in a publick Leture of Anatomy, which undeniably confirms what I have juft now faid. AN Officer, faid he, being wounded with a Sword about two Inches below the falfe Ribs on the right Side, was dretied, as if it had been a fimpie Wound; becaufc there appeared no Accident. But eight Days after fuch diinal Symptoms follow'd, that the Patient died. His Body was opened; and it appeared that the Thruft had pierced the Liver, and that an Abfcefs liad been formed it its Subftance, which burfting, and running into the Capacity of the Abdomen, occafion'd the Accidents juft now mentioned, and the Death of the Perfoni HAD the Surgeon confidered that the Officer flood upon his guard, and that in fuch a Situation the Liver might have been wounded, he would perhaps have cured him by a copious Phlebotomy, and by prefcribing Vulneraries, and a firia Diet. Mr. Operations of SUR G E 5 3 Mr. Lapeyronie told me, that he cured fuch a wounded Man by a copious and frequent Phlebotomy, and by allowing him no other Food but Chicken-Broth. B ECAUSE a prudent and well-experienced Surgeon flould prognofticate right; and bccaufc the Knowledge of the Parts contained in the Abdomen is of great ufe for their Cure; I think one cannot infift too much upon the Accidents attending the Wounds of thofe Parts, fince every particular Sign is very equivocal, and fomething more certain may be inferred from many of them together. I have juft now faid that from the different Regions diftinguifhed in the Abdomen, and from the different Situations and Attitudes of the wounded Perfon, one might conjeture what Part may be hurt yet to be more fully convinced of it, one muft further examine the particular Accidents, which happen in the Wound of each Part. This I fhall endeavour to explain with as much Clearnefs as I can. W E know that a Wound, though penetrating into the Capacity of the Abdomen, does not af-.fc& any of the Parts contained in it, when the wounded Perfon feels only an outward Pain in his Wound, when hardly any Blood comes out of it, when no vomiting happens, when the Patient voids no Blood at the Mouth, nor by the Fundament, or Urine, and when the Belly is neither difended nor fwell'd: In fuch a Cafe, one may very reafonably hope that the Wound may eafily be cured, as I have already faid. THERE is ground to believe that the Diaphragm is affeced, when the Blow is not far from the ReE 3 gion 54 A Trea/;fe of the gion of that Mufcle, when it is dircO'cd towards it, when the Patient can hardly breath, when he has got the Hiccock, and feels a great and deep Pain in his Wound. The Prognoftick of that Wound is very dangerous, and 'tis but feldom that a Patient recovers; for that Mufcle being inflamed, the Infpiration and Expiration are fo conftrained, that he muft intallibly die. Befides, the Blood which continually comes out of that Wound, falling into the Capacity of the Abdomen, ferments, is converted into Pus, and occafions a Fever, an Inflammation, a Gangrene, and all the Accidents above-mentioned. IF the Wound penetrates into the nervous Center of the Diaphragm, the Pain will be moft violent; becaufe the tendinous Parts are very fufceptible of a Vibration. If the Pain is more acute in the nervous Center of the Diaphragm than in its flehy Body, the Spirits muft needs run into it in greater plenty, the Inflammation muft be more confiderable, the Fever more violent, and attended with a Delirium, and Death. IF the Wound reaches only the Circumference of that Mufcle, and does not penetrate into the Abdomen, nor into the Thorax, it is well known that there will be no Effufion in thofe Capacities, and that the Divifion being only in flechy Fibers, which move more eafily, by reafon of their pliablenefs, than the Fibers of the middle of that Mufcle, which are harder and more ftiff, it follows from thence that this Wound will not prove very dangerous, and may be re-united without any great Difficulty. THE Operations of S U R GER YO. 55 THE Wound of the Stomach will be known to the Surgeon, when it lies in the Region of that Vifcus, or is diretced towards it. A prudent Surgeon thould alfo enquire, whether the wounded Perfon had cat any thing before he receiNved the Blow; for the fuller the Stomach is, the more room it takes up, the lower it comes down, and is confequently more expofed to the Inftruments, that may reach the Cavity 0 Belly. BE S I DE S, the Patient feels a great Pain in that Part; he is troubled with a frequent Hiccock; he vomits continually; and if the Infirument, which is the Caufe of all thofe Diforders, has penetrated into the Cavity of the Stomach, befides all the Accidents juft now mentioned, the fick Perfon will vomit Blood; the Aliments will come out through the Wound undigcfited an Inflammation will happen in the Abdomen, and all the Accidents, depending upon this fad Symptom, will crowd in. From whence it minay be inferred, that the Patient will not live long. BUT if the Wound does only open the firft Coats of the Ventricle, or if it penetratcs into its Cavity, and is very ti-nall, one may hope to cure the Patient with a very firir Courfc of Diet, frequent Phlebotomy, &ec. to flop the Vomiting, to moderate the intenfe Heat of that Part, and abate the violent PKi oi it. TH EiLWounds Ot tte In efinesi are kno'i'n by a Tenfion of o Al.omr, and i reat Pin in the Part it felf IThe l ooJP 1 kIit 11 j 11 ters are ejeted th'roee t i Inteftins are op o t Excr, iC h large ones be w nd: Ide"S tICe PaCi; i Blood thro' the aic amnt y A Treatife of the T HE Prognoflick of the Wounds of the Inte flins is much the fame as that of the Stomach; but the Prognoffick of the fmall Inteflins is more dangerous than that pf the large ones; becaufe the former are ecfs (lefhy, and more floating in the!3elly, without being fixed in any place. Bcfidcs, the contirual Lpfs of the Chyle does quickly throw the Patient into a Weaknefs, which makes him die of Inanition. But the large Inteflins adliering moft of tlkni to the internal Surface of the Belly, the flercoral Matters may come out through the Wound without any Extravafation, cfpecially if it lies in the hinder part of the Body, ond it may be cured by healing up to a Scar, or by making a new Anus in that place; of which we have Iome Inflances. Ir is very difhcult to know the Wounds of the Mefcnteiy; and we can guefs at them only by the Depth of the Wound, and the good Condition the other Parts are in. If the Wounds of that Part do not divide any Vcffels, they may bg curedl; but if they happen to be in the Glands, wherein the lactal Veins are re-urlited, they are yery dancgrous; for thofe Veins being opened, the Chyle or the Lymph contained in them will tall into the Cayity of the Abdomen, and occafidn g chyjpus DropfyO: r if thofc Liquors fermen, they will corrupt, irritate the Intelins, and bring upon them an Inflammatipn, which will quickly be attended with 4 Gangrche. Bcfides, the Blood receiing nq longer as much Chyle as it ufed to havq, vill pot be able to repair the continual Loffes it 1fflains by running thbough fo many different 1Parts, wid conecquently thi Patient will dic of Ina, po. TH. Operatons of SUR GER Y. 57 T HE Surgeon knows that the Liver is wounded, by the different Situations and Attitudes the Patient was in, when he received the Blow, as I have already faid, and likewife by the Probe, the Direfion of the Blow, and the Pain felt in the Region of that Vifcus. Thofe Signs, though equivocal, being put together, may give us fome reabfn to believe that the Liver is wounded. THE Wounds of the Liver are very dangerous, and thofe which happen in its concave, Part are much more fo, than thofe which affct the convex Part; becaufe in the firft Cafe, the Blood that comes out in great plenty, and the Abfcefs which commonly follows, muff fall into the Cavity of the Belly, where they occafion all the Accidents, which I have already fo often mention'd. Whereas, when the Wound is in the convex Part of the Liver, the Blood may come out through the Wound, and one may give an fluhe to the purulent Matter by opening the Abfcefs. I may add, that an Abfcefs in the concave Part of that V/fcus is generally mortal; becaufe the Bile diffufing it felf with the Blood, occafions a flow Fermentation, which is attended with a very copious Suppuration, and a total Deftrufion of the Liver, which ends in Death. I T is cxtrcamly difficult to know the Wounds of the Spleen and Pancreas, and the Signs of them are only mere Conjetures, fuch as the Dirction of the Blow towards thofe Parts, Vomiting, and a Fever. Thofe Wounds are very dangerous, by reafon of the Humour they filtrate, which falls into the Belly. I add, that if the Spleen was deroqy'd by an Abfcefs, or any'other way, the Animal 59 A Treat e of the mal would die afterwards of an Abfccfs, that would take up the whole Subftance of the Liver; which may be explained by the Strudure of the Spleen, and the Ufis that are afcribed to it. But bccaufe this concerns Anatomy rather than Operations, I thall fay nothing of it here. THE Wounds of the Kidneys are known by the Place, and Diretion of the Blow, by the Seat of the Pain, and the Blood voided by Urine. If the Wound lies in the hinder Part, and does not penetrate very deep into the Subitance of the Kidneys, it may be cured; but if it reaches as far as the Pelvis, it is a very dangerous, and even mortal Prognoflick; becaufe the Urine coming out through the Wound, falls into the Cavity of the Bclly, and occafions there an Inflammation attcnded with a Gangrcne and Putrefaclion. T H E LWounds of the Ureters are known by the Place, and Dire&ion of the Blow, by the Seat of the Pain, and a little Blood voided together with the Urine. There Wounds are as dangerous as thofe of the Kidneys. W E know the Wounds of the Bladder by the Situation and Diredion of the Blow, by the Pain fitt in that Place, by -the Urine tinged with Blood, and a great Difficulty of voiding it. T HO S E Wounds are more or lefs dangerous, according to the Place they happen to be in; for if the Bladder is opened in its Bottom towards the hinder Part, the Wound is mortal, and likewife in all the places where the Urine may fall into the lely. But when the Wound lies in a place of the gladder, which the Urine does not commonly touch, it is not fo mortal as fome imagine; and to Operations of SUR G ER Y. 59 to prove this Truth by Experience, Mr. Petit affirms, that an Officer having been fhot with a Gun in that Part, he was cut for the Stone feventeen Years after; becaufe the Operator thought he had felt a Stone with the Catheter; but he was very much furprized, when he cxtra&ed a Ball cover'd with a little Tartar. Mr. Mery, fworn Surgeon of Paris, firft Surgeon of the Hitel-'Dieu, and Member of the Royal Academy of Sciences has frequently pierced the Bladder with the Trois-quart, to bring the Urine out of it; which is a further Proof that the Wounds in fome Places of that Part, arc not mortal. THERE is fome ground to judge that the Womb is wounded, from the Situation of the Wound of the Teguments, from the Diretion of the Blow, from the great Pain felt in that Part, and from the Blood that comes out through the natural Openings, when the Wound penetrates into the Cavity of the Womb. The prognoftick of thofe Wounds is always very dangerous: However it is not altogether fo difmal as the Moderns would have it. Wounds of the Womb of all forts, and Abfcefles, have been cured, contrary to the Expctation of thofe who tended the Patients. LAS T LY, the Surgeon fufpe&s that fome of the large Veffels of the Abdomen are opened, from the Quantity of Blood that comes out thro' the Wound, and from the fudden Tenfion of the whole Abdomen. Thofe Wounds arc very difmal, and feldom afford fufficient time to examine them, becaufe the wounded Perfons die immediately. T u 6o A 7reatife of the THE Direfion of the Blow, as I have already faid more than once, is one of the beft Signs we have to judge of-the Part that is affced; for a Thruft with a Sword may be given in the right Hypochondrium; and yet its Diredion may be fo oblique, that it does not reach the Liver, but the Stomach. To make an End ofthe prognoflicks concerning the Wounds of the Abdomen, I ihall ay in general, that thofe Wounds which penetrate without hurting the internal Parts, are commonly cured without many Accidents, provided the Surgeon be not fo imprudent as to fearch and irritate the Wound, together with the internal Parts, and to fill it with Lint. W HEN the Epiploon comes out alone through the Wound, the Prognoftick is not by a great deal fo dangerous, as when the Intettin only comes out. And if the Epiploon and the Inteftin come out together, the Difeafe is not fo bad as when the latter comes out alone; becaufe the Epi/loon is a foft Body, which keeps the Inteftin from bcing too much preflfed, and makes its Redudion miore cafy. 1V HEN the Intcflin comes out throuygh t he Wound, there are certain Signs whereby one may know whether it be wounded, or not. Firfi, when it is not at all diflended. Secondly, when the Surgeon draws it a little out of the Belly, and it does not fivell. Thirdly, when being reduced, it fmeclls like the Excrements. In thcf Cafes, there is ground to believe that the Inteftin is woundcd. But becaufe the different Wounds of the Intefltins are more or kfs dangerous, a prudent Surgeon Operations of S u R GE R Y. 6i Surgeon ought to examine them well, that he may find out fome curative Indications. Here follows what Mr. Petit fays of them. If the Wound of the Inteftin be tranfverfe, no other Fibers but the longitudinal are cut, and the circular remain intire. If it be longitudinal, the circular Fibers are cut, and the longitudinal remain untouch'd. But if the Wound of the Inteflin be oblique, both Plans of Fibers are cut, and that Wound is the mofi dangerous, becaufe it remains always gaping, and confequently lefs diffofed to a Re-union. I N order to perform the Operation of the Gaftf rorhaphy, we muft fuppoi~ complicated Wounds, which abfolutely require fuch a Help. There are three Sorts of them. The firft, when the Wound of the Abdomen is very large, with an Effufion in the Capacity, and an Iffue of the parts contained in it. The fecond, when the Inteftin is partly or totally cut, and confcquently does not come out through the Wound, becaufe being pricked, it does not roll fo cafily or if it comes out, one may know it prefently, becaufe it is generally very flaccid. Laftly, the third fort of complicated Wound is when the Inteftin or the Epiploon comes out through the Divifion, and even both of them together, the firft fwelled, and the other corrupted, and when all thofe Accidents are attended with a Conftridion of the Skin. BEFORE I proceed further, I muft obferve that though I inftance in a diftended Inteftin, yet that Symptom does not happen as foon as the Inteflin comes out, and that it fvclls only fome time after, becaufe fomc matters get into it by Degrees, 6z A Treat;fe of the Degrees, which not being able to come out again through the other End, by reafon of the Confiridion, ferment and occafion the fwelling of the Inteftin. That Swelling is further increafed by an Inflammation proceeding from the Blood of the Veins, which ftops there, and not being able to follow its ufual Courfe, muft needs ferment, and thereby occafion a confiderable Tenfion in the Inteftin. THE Benefit to be reaped from this Knowledge is, that though the Intcftin appears at firft flabby yet one muft not infer from thence that it is wounded; for we make a great Difference between flabb and flaccid. The Sight, and an exac Pcrquifition, will clear thofe Doubts. T E Operation of the Gaflrorhaphy is proper for thofe three forts of Wounds: But becaufe Repetitions arc tedious, I fhall explain here the Difficultics attending each particular Wound, and defcribe exaftly the Method of performing the Gaftrorhaphy, when I have difcourfed of the third Wound, which is one of the moft complicated, and the moft proper to give us all the neceffary Light into this Matter. I F therefore a Thruft with a Knife, a Bayonet, or fome other like Inflrument, fhould occafion a Wound in the Abdomen; if the Inteftin, the Epiploon, or both of them together, fhould come out; and if the Wound being recent, the Con. ftli&tion fhould not be yet very confiderable; the Surgeon muft immediately warm a Piece of Linnen folded into three or four Folds, and cover with it the Parts that are come out, to preferve their natural Heat, and prevent the Impreflion of the Air, which Operations of SuRGER Y. 63 which is very prejudicial to them. At that very Moment, he muft dip a Piece of Linnen in warmn Water, and wrap up the Parts with it, after he has wiped off the Blood that may lye upon them: Or elfe, let him ufe, an emollient Decodion, fuch as that of Morels, Mallows, and AMar/h-mallowss, laying afide all fpirituous Liquors, becaufe they contain coagulating Acids. Afterwards the Surgeon muff reduce the Parts into the Belly; but bc. fore he makes that Redudion, which the Antients called Taxis, the Patient ought to be put in different Poftures, according to the Situation of the Wound. If the Wound was above the Navel, the Patient's Breaft fhould be more raifed than the Belly: If it be lower than the Navel, fomething muft be put under his Loins, that the hypogafirick Region may be higher than the epigaftrick: Laftly, if the Wound be in one of the Sides of the Belly, the Patient muff be turned on the oppofite Side: All thofCe diffcrent Situations are only of ufe to difentangle the Place of the Wound from the Parts of the Abdomen, that the Remainder of thofe Parts may not thruft againft the Wound, and that the Redudion of thofe that are corne out, may be more fpeedily and eafily performed. THE Surgeon muff take care to cut the Nails of his two Fore-fingers, left that ihould make a dangerous Impreflion upon the Inteflin. He mulf lay the Fore-finger of one of his Hands above the Inteftins, efpecially the End of the Finger towards the Place of the Inteffin that came out laft, and a little beyond the Confiridion. Afterwards fliding it towards the Wound, and withdrawing it a little, he mult thruff the Intefin till the Finger gets 64 A Treatfe of the gets intd the Belly; and then under that Finger he mufft convey the Fore-finger of the other Handy with a fmall Portion of the Inteflin, till he perceives that the firft Finger may be removed, without any Danger that any other Parts fhould come out: So that the Surgeon muff always have a Finger upon the Inteftin to fecure it; and as he withdraws it, the other Finger muff take its Place, till the whole Bundle of Inteffins be reduced. IF the Wound was in the Middle of the Rectus, and under the Navel, the Operator muff take care, when he reduces the Inteftin or the Epiploon, not to engage them between the Mufcle and its Cover, which under the Navel is hardly adherent to the Mufclc, there being generally no nervous Interfetions in that Place. The Surgeon might then fancy, he has reduced the Parts into the Belly; and thofe Parts being conffrained between the Mufcle and the internal Side of ifs Cover, would be attended with Inflammations; great Pains, Watching, a 'Delirium, a Fever, and perhaps Death it felf. We are indebted to. Mr. Arnaud for this Obfcrvation, which appears to me very important. I F the Epiploon comes out with the Inteftin, both of them ought to be reduced, beginning always witlx the Inteftin, as being come out lat-' but whilft the Surgeon reduces the Inteftinw into the Belly, a Servant muff hold the Epiploon', that the Inteftin may flide more eafily. The Servant holding the Epiploon ought to do it with a great dcdl of Dexterity, for fear of bruifing that fat Mernbrane, and occafioning in it an Inflammation; or a Mortification. The Inteffin being reduced in the manner I have juff now faid, the fame ought to Operations of S u R G R v. if to be done with the Epiploon, fince we fuppofe that.the Wound of the Tegumcnt is recent, and that the Epiploon is not at all, or but Jittle altered. Afterwards a Servant muff hold the two Lips of the Divifion one againft another, whilft the Operator makes himfelf ready to perform the Gaftrorhaphy, which I fhall defcribe at the End of my Account of that fort of Wounds. THE Surgeon fhall make a Fomentation upon the Belly with warm Oleum rofatum, applying upon it a Comprefs dipt in warm Wine, or in Water and Vinegar, the whole being fupported by a Napkin and Scapulary. The Patient muff lye upon the Wound to facilitate the Ejefion of the Blood, or of the Matters extravafated in the Belly, if there are any. He muft be blooded plentifully, to prevent a Fever, and other Accidents; and the Surgeon ihall prefcribe to him fome GlifT ters, and a ffrit Courfe of diet. TH E Cfcond Wound to be cured, is when the Inteffin is partly or totally cut. THE Wound of the Inteftin, in confequence of the Wounds of the Belly, is feldom cured, as it appears by the Experience of the learned Surgeons fo often quoted by me. Thofe forts of Divifions are, as I have already faid, tranfverfe, longitudinal, or oblique; and each of them is fmall, middling, or large, or the Iriteftin is altogether cut; and in this laft Cafe, it feldom comes out through the Wound of the Teguments, unlefs it be vety large. IF the Wound be very fmall, which way foever the Fibers be cut, it is not neceffary to make a Suture, and it may be cured without fuch an Operation. If the Wound be not too large, fome f modern 66. A 7Teat;fe of the modern Surgeons advife to make a Stitch in the middlc of i. That Prafice ought not to be admitted; for every interfe&ed Suture fuppofes a Knot after a Stitch, which would hinder the withdrawing of the Thread, when the Wound is cured, and occafion great Accidents, as I am going to fhew. The Surgeon muff therefore, in fuch a Cafe, cfpecially when the Wound is very large, put into Pradice the fecond Sort of Suture, which I have called the Skinner's Suture. According to the ufual Way of making that Suture, the Operator pierces the two Lips of the Wound tranfverfly, and at once, and begins the fccond Stitch two Lines under the firft, and on the fame Side, faftening the End of the Thread under the fecond Stitch, to avoid making a Knot. Afterwards he continues to fow the Wound, and in the laft Stitch he paffes the Thread, or the Silk he makes ufe of, under the laft Stitch, not to make a Knot. That Method of fitching the Wound always in the fame Side, is the Reafon why that Suture has been called the Skinner's Suture. A L L Authors, both ancient and modern, are agreed that after a certain time the Surgeon ought to draw the Thread, withl which the Wound of the Intcftins has been futured, without difordering the Wound of the Belly. But I ask whether that Thread can be drawn out of the Wound, when it is engaged in the two Extremities of the Suture, under circular Turnings with the fame Thread continued, and what Diforder will not happen upon fuch an Endeavour. There is no Need of mechanical Proofs to condemn that Method, every body may eafily judge of it. OTHER Operaticms of RS U R GE R Y.? OT HER Surgeons, who are more judicious; do not faften the Thread at the Ends of the Suture but, as all the Authors teach, they pierce trantverfly the two Lips of the Wound of the Inteftin at once. TH E Surgeon cannot withdraw the Thread by one of the Angles of the Wound, after he has pierced the Inteffin tranfvcrfly, without fitraitening anew every Stitch, and contrading the Inteftin; becaufe the Turnings of the Thread, that are without, are oblique, and make acute Angles with thofe of the Infide, which defcribe tranfvcrfe Lines. N o r to fay that according to this Method the Surgeon cannot withdraw the Thread, when the Wound is re-united, he occafions fo great an Inflammation in the Intcflin, by contraling it, that. the Wound is quickly attended withl an Inflammation and a Gangrene. In order to avoid all thofe Accidents, Mr. TPetit makes that Suture i: fuch a Manner that all the Turnings together are like a Line fomewhat fpiral, which has no Angle that can ftop it, the Obliquity of the Thread being equally in the Infide and Outfide of the InJ feflin. The Surgeon ules a flat and waxed Thread, and puts it into the Eye of a ftrait Needle, the Sides of which are cutting, of good Steel,.and of a Bignefs fuiitable to the Thread. Afterwards a Servant holds one of the Angles of the Wound, and the Surgeon holds the other with his left Hand, whilft with his right he conveys the Point of the Needle obliquely fron without inwards, one Line above the Divilion: He pierces oblique-- ly a Lip of the Wound, and then the fecond Lip' Fa likewif-' 68 A Tieat;fe of the lkewife obliquely one Line under the firft, and from within outwards, that he may repeat the fame, in order to make an End a little belbw the Wound. BY this Obliquity the Thread defecribes almofft a ftrait Line, or one that is but very little fpiral, and it may cafily be drawn. The Surgeon muft alfo leave the Thread long enough at both Exremities of the Wound of the. Inteftin, that he may apply it in its whole Length to the Wound of the Peritonxaum, to facilitate the Re-union of it, being perfuaded that it cannot be made without! agglutinating it feilf to tome adjacent Part: And he places the two Threads at the two Angles of the Wound of the Belly, to perform the Gafirorhasphy; and then he draws the two Threads, to bring them more exaftly near the Peritonaum, and he drcffes that Wound as the foregoing. T H E Succefs of this Operation is very uncertain, as I have already Laid; and therefore the Surgeon ought to make a very doubtful Proanoftick; he muft blood the Patient, nourifh him every Day only with three or four Yolks of new laid Eggs, and at the End of three or four Days allow him a finall Quantity of Broth, and Jellies. The Patient muff take nouriflhing Gliffers: This Expedient ought not to be rejeacd, fince Anatomy didcovers to us ladeal Veins, which arife from the large Inteflins, efpccially from the Colon. Thofe Veins can therefore take up the moft fubtil Particles of Glifters, and by that Means nourifh the Patient for fome time. T ~ is Argument, grounded upon the Strudure of the Parts, is further confirmed by Experience. We Operations of SURGERY. 69 We have fccn in the Hotel-'Dieu at Paris a Woman, who not being able to take any Nourifhment through the Mouth, bccaufe the had been fhot in the Jaw with a Fire-arm, yet recovered, having only taken nourifhing Glifters for a fortnight. Since that time I have fecn in that Hofpital feveral Perfons nourifhecd in the iame Manner. IF on the fifth or fixthDay, the Thread grows loofe, and the Patient feels fome fmall ColickPains, 'tis a Sign that the Suture of the Intcftin becomes an extraneous Body, and that 'tis time to take it off., In order to do it fafely, the Surgeon cuts one of the Threads at one of the Angles of the external Wound, and laying his fore and middle Fingers on both Sides of the other End of the Thread, he draws it gently, leaving fiiH one or two Days the other Threads, if there are any, in the Epiploon. MR. Arnaud does ingenuoufly confefs that he never faw any Cafe of this Nature, wherein the Surgeon was obliged to make the Suture of the Inteftin. I faw it made once, in the Hopital de la Charite at Paris, upon a Chair-man, who had been wounded with a Knife in the Belly. Mr. Guerin, fworn Surgeon of Paris, and Mafter Surgeon of the Hopital de la Charite, performed the Operation; but the Patient died on the third Day. If the Inteftin be altogether cut, the Surgeon muff fecure the End of it, which comes from the Stomach, being perfuaded that Death is near at Hand, if the ftercoral Matters fall into the Cavity of the Abdomen. He niay ditinguifh that En1d of the Inteflin from the othecr, by the MatF 3 tcrs" 70 A Teat';fe of the tcrs, which continually come out of it; and wiheq he knows it, he muft, if poflible, make a Ligature at the other End, and put it into the Belly, letting however the Thread, (which ought to be waxed,) come out through the lower Part of the Wound. As for the Extremity continuous to the Ventricle, it muff be faftened in the Circumference of the Divifion of the Belly with feveral Stitches of an interfe&ed Suture which is performed by piercing with a Needle the Inteftin and the Teguments at the fame time, and by that Means a new Anus is made. The Surgeon makes the Knots of the Stitches in the Outfide of the Wound, and with the neccffary Caution. He puts into that new Anus a foft Tent, covered with fome fpirituous Balfam, and tied with a Thread, left it thould go into the Inteftin, and over it a Plagct, rc. I F the Surgeon perceives never fo little, that this Tent occalions fome dangerous Accidents, he ought to take it out: The fccal Matters, continually running through the Wound, hinder it from being re-united. THE modern Books jtflify the Pradice of a new Anus by an Experiment made at the Invalides upon a Soldier and befides that the Ancients afford us many Inflanccs of that Prafice, Rcafon cannot be againft it, fince it is the only Way of preferving the Patient's Life. LASTLY, to put an End to our Refletions concerning the Wounds of the Abdomen, I flall in the next Place difcourfe of the third Sort of complicated Wounds, which I have mentioned above. In thofe Wounds the Inteftin and Epiploon oqmp out, the former very much fwelled, and the lattcr Operations of SUR GERYR. * 71 latter corrupted; and all thofe Accidents are attended with a Confiridion in the Skin. XWV EN the Surgeon is fent' for to attend a wounded Perfon in fiich a fad Condition, he muff, before he attempts any Operation, apply fome Remedies that will mollify the Inteftin, and abate its Inflammation. The Surgeon fhall make a Foinentation with emollient Herbs, warmed with proper Oils, as thofe of Fennel and /ninffeds. HAVING bathed and fomented the Inteftin with thofe or other like Remedies, according to his Experience, he muff handle it a little to remove the Winds, that may be contained in it. Some Surgeons, and Ambrofe Pareus among others, would have the Inteffin to be pricked with a Needle; and fome fay, it muft be round, for fear of cutting the Fibers of that Pipe, as a flharp Needle Would do. This Difpute is of Lmall Importance, and hardly deferves to be confuted or approved. IT may be faid in general, that things ought never to be brought to this Extremity, but when there is a great Bulk of Inteftins come out, and when they are Lo full of Wind that they cannot be reduced, even after having fufficiently dilated the Wound of the Teguments, and tried all the Means, which Art and Skill can invent for that Purpofe. In fuch a Cafe, it is better to prick them, than to fuffer the Patient to die; which would refled very much upon the Surgeon. But then he ought to take his Meafures fo well, and conceal his Inftrument to dcxteroufly, that the itanders by may nor perceive it. IF the firft Method proves ufclefs, and does not quickly facilitate the Reducion of the Intcflin, the 'F Sirgeon 7 z A rebt;fe of the Surgeon muft dilate the Wound of the Belly." In order to make that Operation, he muft cut the Skiin, the Fat, the Mufcles, their Membranes, and the Peritonewum, bccaufe the Conftriftion is in thofe Parts. But as the firft Obftacle is to be found in the Skin, and we know by opening the dead Bodies of thofe, who had a Wound in the Abdomen, that 'tis extremely difficult to reunite the Periton~e urn, this Part ought to be ufed with the greateft Caution, and the Surgeon muft cut a greater Quantity of the external Teguments, wlich may more cafily be re-united, efpecially the Skin and the Fat. By this careful Mythod, the Operator will perhaps prevent the Ruptures of the Belly, which are commonly a Confequence of that Difeaie, and frec quently occafion the Death of the Patient. BEFORE the Surgeon proceeds to this Operation, he muft prepare the Infitrments proper for it, the firft of which is a hollow Probe, flopped at the End. Its Groove ought to be proportioned to the Bignefs of the Infitrument, that muft flide in it; for otherwife the Surgeon would run the Hazard of mifcarrying in the Operation. The fecond Infirument is a crooked Biflouri, the point whereof fhould be fomewhat blunt, and its Blade made faft with a Fillet. AFTERWARDS the Operator mufft look for a Place in the Wound,. that is the moft proper to make a Dilatation; and it mufft be, as much as poffible, in the Angles of the Wound, efpecially on that Side where the Inteflin inclines lcafit, avoiding the Linea alba, and the Courfe of the umbilical Vein, if the Surgeon be near it. For -fome Operators have been very much furprizdl to fee, iq fuch Operations of SURGERY. 73 fuch a Cafe, the Blood gufhing out from that Vein: Wherefore if the Wound be above the Navel, the Dilatation ought to be made underneath; on the contrarv), if it be underneath, it muft be made above the Navel. ALL thcf2:Circumftances being duly obferv'd, the Surgeon wraps up the Parts, that are come out, in a Rag dipt in warm Water and then, by means of the Inteftin, which he keeps fteady with his leftHIand, he endeavours with his right to introduce the grooved Probe. THE Surgeon drives the Probe rather over the Inteftin than over the Eiptloon. The former, if compared with the other, being a fteady and folid Body, does very much facilitate the Introduftion of that Inftrument. On the contrary, the latter being a tender and flabby Part, not only yields to the Probe, but alfo is apt to tear off, and renders the Wound more complicated, and the Operation more difficult, WHEN the Surgeon is fo lucky as to introduce the Probe in this manner, he muft convey it near the internal Coat of the Peritoneum, moving it a little on the right and left, to fee whether it touches it immediately, and whether there be not any thing between; which the Operator may know, when he feels a fmooth Body, which makes fome Refiftance. AFTERWARDS the Surgeon takes the Probe with the left Hand, and the Biflouri with the right, which he holds like a writing Pen, and conveys it into the Groove of the Probe, nearer the left Hand than the Parts he defigns to cut, fliding the Back and Point of that Inftrument all along the Groove, '-r u * i. IOf 74 A Treat;f of the of the Probe, which he muff keep fteady, the left Hand being without Motion in that firt Cutting, which fhall be made with the Edge of the Biflouri to unbridle the'Peritonxum and the Membranes. Without quitting the Inftruments, the left Hand which was at reft, flall be in motion, and the other fhall hold' the Point of the Bifiouri in the Groove of the Probe, without flirring, whilft the Surgeon raifes the Point of the Probe, to cut the Conflridion of the Skin with the Edge of the Biffouri. B u T if the Conftrition be fo conflderable that 'tis impoflible to convey the Probe into the Belly, the Surgeon muft ufc a fmall Stilet with a Button at the End of it, and with the Help of the Stilet he ihall convey the Probe to do what I have juff now dcfcribcd; or if the Stilet cannot cafily get in, he muft apply the fore-Finger of the left Hand upon the Intcftin, to remove it from the Confiridion, as much as he can, cutting the Skin upon the Nail of his Finger with the Point of a crooked Bijtour. The Operator having loofen'd the Skin by means of that fmall Opening, moves his Finger forwards, and cuts part of the Mufclcs and Skin at feveral times, till he makes in the external Teguments a fufficient Opening to introduce a Probe, in order to dilate the Peritoneum. SIN CE the Surgeon ought to ufe the Peritoznum more cautioufly than the Skin, I would advife him to cut the Teguments, and the Peritonxum, (the Probe being in the Belly) in the fame manner as he cuts them upon the Nail; becaufe he fees what he cuts, and can make as great a Diyiflon as he thinks fit, cfpccially in the PeritonaXum and the $kin. W Operations of SURGERY. W E are indebted to Mr. Petit for a new Method of dilating the Confiriaion, and it is preferable to all others, as being quicker and fafer. It confifts in having a imall firait BV/louri with a blunt Edge, and a Button at the End of it. TH E Excellency of that Inifrument appears by its dilating the Wound without fo much ado; be. caufe it may be plunged into the Belly, without piercing or cutting the Parts contained in it. However, it cuts fufficiently to divide thofe that are diflended and ftretched, and which make fome Refifltance, fuch as the Peritonaum, the Membranes of the Mufcles, and the Skin. T H E Operator having dilated the Wound, and removed the Obitacle, that prevented the Redu&ion of the Parts into the Belly, muff reduce the Intecitn in the manner above-mentioned, whilft the Servant holds the Epiploon. Afterwards he makes him hold the two Lips of the Wound brought near one another, that the Inteftin may not come out again, and confiders whether the Epploon be gangrened and rotten. If it be only fomewhat blackifh and livid, it muft be reduced: The natural Heat of the VYfcera will reffore, if I may fay fo, the Life it feernmed to have loft. Some good Praftitioners have reduced a great part of the Epiploon, which appeared blackilh and livid; and the Patients recover'd, without any Accident arifing from thence. Thofe Surgeons took that Courfe, being perfuaded that the Epiploon, when tied, did fuppurate, and that the Matter falling upon the Inteftins, and confequently into the Belly, occafioned fuch lad Accidents as were quickly attended with Death. THE 7 4 A Treat ~e of te T HE Suppuration of the Epiloon is yet more encreafed, upon another account; becaufe Surgeons generally make the Ligature in the found Part; and after they have reduc'd it, not only tih dead Part fuppuratcs, but alfo the found once contained under the Ligature: Which would no-t have happen'd, if that fat Membrane had been reduced, without making a Ligature in it; and no other Part but the dead one at moft would have fuppurated. Wherefore, if a Suppuration cannot be avoided, it is as well to reduce the altered Epp/loon, as to tie it. Laftly, if notwithflanding all thefre Arguments, a Surgeon refolves upon the Ligature, there are two ways of making it: The firft, when there is but a fmall Part of the Epiploon to be taken off, and confequently the Part, that is tied, cannot be very conftderable. In this Cafe, the Operator makes a Servant hold the Extremity of that Membrane, and then ties with a Fillet fuch a Part of the Epiploon as he thinks fit, making the S.urgeon's Knot, that is, a double Knot; becaufe in order to make it, he paffes the Thread twice into the Loop; and above that Knot he makes a fingle one, that he may the better flop the firit. IF we make at firft a double Knot, 'tis in order. to prevent the loofening of the Fillet, whilft the fecond Knot is making: And if it be faid, that the double Knot is not fo binding as the fingle one, we anfwer, that it would be a Fault to fitraiten it fo exadly, ftince by that means one would itoun the Hazard of cutting that fat Membrane, Which makes no great Refiflance; and the Ligature is fufficiently' flraitemcd, whlct it flops the B lood, Operations of SURGERY. 77 Blood. Afterwards the Surgeon cuts the Thread at the length of half a Foot, and the Epiploon about an Inch on this fide of the Ligature. T HE fecond way of making that Ligature, is when a great Part of the Epiploon muff be cut, and when the Surgeon forcfees that the Part tied will be very bulky. In fuch a Cafe, he ftretches the Epiploon, and examines through the light the place in which there are fewer Veffcls. Afterwards he pafles through the Epiploon a Needle with another like Thread. He takes away the Needle, and ties the Epiploon on one fide with a fingle Knot, and then makes a Turning with the Thread in its Circumference, and one Line above the half Turning, which he flops with two fingle Knots. Laffly, he cuts the Thread at the Length of half a Foot, and then the Epiploon about an Inch on this fide of the Ligature. I F the Surgeon makes only fingle Knots in this Cafe, it is becaufe there is a greater part of the Omentum, and becaufe the fecond Knots are made in the fide oppofite to the firft. I muft obferve that I make but one Turning with the Fillet in the firft fort of Ligature, and one and a half in this, to avoid making too great a Bulk, like thofe who make three or four Turnings; which muft needs be attended with bad Confequences, and too plentiful a Suppuration. THE Ligature being made, the Operator conveys the Epiploon into the Belly, and places the Fillet in one of the Angles of the Wound, to perform the Gaflrorhaphy and to fuccced in it, he muff pradife every thing the Art of SURGERY affords, to overcome all the Difficulties. THx 78 A Treatfe of the THE Surgeon fhall have Needles 6f good Steel, fharp-pointed, and cutting, that he may cafily pierce the Skin, which is very clofe and hard in the Abdomen, and confequently, as Mr. 'Duverney rightly obferves, more difficult to pierce in that Part than in all the others. THE Figure of the NeedleS mtift not be like a Bow, as is defcribed in all ancient and modern Books; becaufe the Surgeon could not fupport their Heads upon the Ball of the Thumb, and at the fame time conceal the Point with the End of the fore-Finger. Their true Figure therefore ought to be this; they muff be ftrait, the two third Parts of their Length, and the Remainder, as far as the Point, muft be crooked. BECAUSE the Skin makes a great Refiftance t' the Needle, and the Surgeon might hurt that Part of his Hands on which the Needle's Head lies, he muft ufe a fmall Port-Needle, or rather Mr. Petit's Ring above defcribed. He may put it on his Fingers, or Thumb, and it is very convenient to perform that Operation. THE Surgeon fhall pafs a Fillet, made up of eight or ten Threads, into the Eye of two Needles, one at the End of each Fillet: Afterwards he fhall convey the fore-Finger of his left-Hand upon that Lip of the Wound, which is fartheft from Shim, that he may turn up the 'Peritoneum and the Teguments; and drawing the Peritonxum with his fore-finger, he fhall pufh back the Teguments with his Thumb. I Nthe next place, the Operator fhall take one of the Needles with his right-Hand, its Head reft. ing upon the Ball of the Thumb, and lying along the Operations of SURGERY. 79 the Infide of the fore-Finger, the Thumb holding it, and its Point being concealed by the fore-Finger, for fear of hurting the Intcftins by conveying it into the Belly: But bccaufe the Skin cannot be cafily pierced, the Surgeon fhall ufe the Ring but then the Needle muft be fomewhat fhort. THE Surgeon conveys the Point of that Needie, which is concealed by the End of the foreFinger of the right-Hand, under the Lip already made faft with the left-Hand: And becaufe the fore-Fingers crofs one another, which is a great Obftacle to the rood Succefs of the Operation; the Surgeon mutt bring his Elbows as near his Breafi as he can, to avoid that Inconvenience. Afterwards he pierces with the Needle pretty deep into the Teguments; becaufe the continual Motion of the Belly might break the Suture; and he pierces in the Middle of the Lip, if the Extent of the Wound requires but one Stitch; and if the Surgeon is obliged to make two Stitches, he always begins with that place, through which the Inteftin may more eafily come out. W ITHOUT removing the fori-Finger of the left-Hand from the infide of the Wound, he conveys it under the Lip, that remains to be pierced, drawing the Teritonxum towards the Lip idft before pierced; and drawing the Teguments, he takes with the right-hand the Needle, which is at the other End of the Thread and inflead of bringing the Elbows near the Breaff, he mufft remove 'cm from it, and pierce with the fame Circumftances I have juft now defcribed. M os T Authors tell us, that this Suture ought to be faftened with a Knot, and a Loop upon that Lip, 8 A Treatff of the Lip, which is lefs liable to difcharge the Mattes. B T if there be a Suture, that requires Quills, it is doubtlefs this, fince it muft be able to refift the continual Motion of the Wound, which lies in Mufcles fo neceffary to Refpiration. And by virtue of that great Motion, the Threads might tear the Lips of the Wound, if their Effort was not flopped by that Means. THE Surgeon muff therefore divide the Fillet into three, as it was done in the quilted Suture, and apply a Quill upon each Lip of the Wound, which ought to be fattened with a Knot, and a Loop made with two Threads of the Fillet. Afterwards he draws a little the Ligature of the Epiploon, and places it in one of the Angles of the Wound, to apply upon it a Plaget armed with Arc~us's Balfam 5 becaufe it excites a gentle Suppuration, which is neceffary in this Cafe; and the better to fecure the Plaget, and the Suture, he makes a Knot, and a Loop upon the Plaget with the third Thread, left on each fide of the Wound. He thall rub the Belly, and particularly the whole Circumference of the Wound, and the Navel, with Oleum rofatum, warmed with a little Brandy. He muff lay upon. thofe Parts a large Comprefs with the fame Medicament, and over that another dipt in warm Oxycrat the Whole being fupported by a proper Bandage, as I am going to fhew. Of Operations of SURGERY. 8 Of the Bandage known by the Name of NAPKIN and SCAPULARY. THE Dreflings of the Abdomen and Breaff are generally fupported by the Bandage called the Napkin and the Scapulary. It is a compounded Bandage; and in order to make it, the Surgeon takes a large Napkin, much longer than broad; he folds it into three, according to it s Length, and then rolls it at the two Ends, to apply it more conveniently about the Body. He lays the Middle of it upon the Apparatus, and then carries it round the Body, holding the Rollers in his Hands, and puts one of the Ends under the other, to pin it where it ends. THAT Napkin may grow loofe, and come off from the Apparatus; and therefore the Surgeon keeps it on by the Scapulary, which is a Piece of Linnen, about fix Inches broad, and above three Feet long for the Wounds of the Abdomen; but the Length of three Feet is fufficient for thofe of the Breaft. He folds that Linnen into two, according to its Breadth, that he may know the Middle of it exaftly: He makes a Slit in the Middle about five or fix Inches long, according to the Length of the Linnen; and then he unfolds it to pafs the Patient's Head through the Slit; and the Middle of the Linnen being upon the Shoulders, he pins upon the Napkin the Ends hanging before and behind. MOST Surgeons are of opinion, that a Tent fhould be put into the lower Part of the Wound, to keep it always open, (fay they) that the purulent G Matter 8S. A Treatfe of the Matter proceeding from the tied Epiploon may eafily come out. Some will have it to be very large and crooked, for fear it thould hurt the Inteflins, as they pretend. Others being fenftble that a long and large Tent may be prejudicial, ufe only a fmall one. As for me, I am of a very different Opinion; for I do altogether rejef the Ufe of a Tent, looking upon it as being needlefs for feveral Reafons. Firfl, THOSE who make ufe of a Tent, do it to facilitate the coming out of the purulent Matter, by keeping afunder the lower part of the Wound. But fince I have proved that Quills are abfolutely necefary to fupport the Suture, it is ea. fy to infer from thence, that the Lips of the Wound are at a fufficient Diftance, to make way for the Matter. Therefore a Tent is ufelefs. Secondly, IF that Tent be introduced to help the Difcharge of the Matter, far from having that Effed, it will flop the Paftage. The Matter muft therefore remain in the Wound from one Drefling to another; and fuppofing it might be taken out in dreffing the Wound, yet during that Time, it will diffufe it felf into the Cavity, together with the Inteftins; it will ferment, and occafion an Inflammation, a Gangrene, and Death. Therefore a Tent is not only ufelefs, but even pernicious. Thirdly, THAT Tent muft abfolutely reach much farther than the Peritonaum to remain in the Wound; and therefore thofe who are for it, take care to fow the End of it, that it may not (fay they) hurt the Inteftins: But this will not hinder it from occafioning the Accidents juft now mentioned; or clfe it flould be pierced in the Middle. Befides, though Operations of S U R GER t though it fhould not reach beyond the RPeritonnund above one Line, yet it is a hard and uneven Body, which the Interfins cannot touch without beIng irritated, bruifed, inflamed, &c. Therefore that Tent is very prejudicial. Fourthly, I F a Surgeon, in Imitation of thofe' who acknowledge part of thefe Inconveniencies, puts in only a fmall Tent of Lint, he may be fure that the epigaftric Mufcles, not being able to refifi the Motions of Infpiration and Expiration, and the Inteftins being always in perifialtic Undulations; I fay, he may be fure that thofe Vfcera will quickly repel it, and that it will not remain a quarter of an Hour in the Wound. Therefore it is ufelefs. I might alledge feveral 0thet Iteafonsi to condemn the Ufe of the Tent. For inifance, a Tent infiltrated with Pos, or other Matters, will make the Lips of the Wound livid, hard, and callous; and if the Salts of the Pus are coarfe, they will irritate the Skin, and bring an Eryfip'elas upon it; which is fuch a difmal Accident, that it occafions the Death of the Patient, notwithfianding the great. Care of the Surgeon. TH E beft Situation for the Patient, after thd Operation, is to lie upon his Wound, that the Pus may ftill come out, and the EpE ldoon mord eafily adhere to the Peritoneum. T E Patient fhall be confined to a Very firid& Courfe of Diet. A frequent Phlebotomy will eafr him very much, and emollient and foftening Glifters notVonly relax the Fibets, and dilute the Matters, but alfo refrefh and calm the Motion of the Blood and Spirits, and prevent a Fever, which is Ga mucich 84 A Treatife of the much to be feared. Gentle Vulneraries may alfo be uCfed in the manner I have preferibed after the general Precepts relating to Wounds. T H E Wound muft be dreffed twice a-day, as I have jufi now flhewed; and on the fixth or feventh Day, the Surgeon muft give fmall Cbncuffions to the Ligature of the Lpiploon, taking care not to ftrain any Part; and when it is taken off, and the internal Suppuration is quite over, inflead of Arcau1s's Balfam, he fhall ufe a fpirituous and balfamic one, and flhall not take off the Suture till the Wound be perfcIly cured. I F the Epiploon comes out alone after a Thruff with a Sword, or fome other Infirument, and cannot be reduced by reafon of the Smallnefs of the Wound, the Surgeon ought not to make a Dilatation of that Wound, nor a Ligature of the Epiploon; but it will be much better to cut it level with the Skin, having firft examined whether it contains fome Circumvolution of an Inteffin. Afterwards the Surgeon dreffes the Wound with a Plaget dipt in a fpirituous Balfam. Which has been praaifed by Mr. Arnaud with good Succefs. 00:D 00 V 10)4: 1%j* IS O0 CHAP. V. Of Hernias. A Hernia is a preternatural Tumor, which hap' pens in the Circumference of the ltly, and is occafion'd by fome folid Parts, or the fettling of fome Huniours. Operations of SUR GER Y. 85 I fhall treat in this Chapter, of thofe Tumors, that happen in the Circumference of the Belly, and are occalrtoned by the coming out of fome of the floating Parts contained in it; and then I flhall difcourfe of Hernias occafion'd by Humours, called by fome Spurious Hernias, and more commonly known by the Names of Hydrocele, Sarcocele, &c. T H E Tumors of the Circumference of the Belly, occafion'd by fome of its floating Parts, are called in general true Hernias; but each of them is diftinguilhed by its proper Name, according to its Situation, and the Parts it contains. BE I N G conftder'd with refpect to the Places they are in, they are called inguinal at the Groin; crural in the fore and upper part of the Thigh; exomphalous or umbilicalin the Ring of the Navel and thofe which happen in the other Parts of the.dbdomen, are named ventral. BESI D ES thofe Sorts of Hernias, fome are alfo to be feen in the Interval of the two Refi, viz. from the Navel to the Xiphoid Cartilage; and thefe frequently appear in Children. The others appear from the Navel to the Pubes, and are more common in thofe Perfons, who have beenconfiderably fwelled, in Women who have born many Children, and thofe who are with Child. Laffly, IN relation to the Place wherein they {hew themfelves, they are alfo called complete and incomplete. For inflance, when they fall into the Scrotum, or into the Lips of the natural Parts of Women, they are called complete; and when they are confined to the Groin, incomplele; and both Sorts are either with or without Conflriction*; G3 or 8B6 A Treattfe of the or with an Adherence of the Parts that are come out, or without fuch an Adherence: But thofe two things are frequently to be feen together. Hernias being confider'd with refpea to the Parts contained in them, have alfo different Names, For inftance, if the Inteftin raifes the Skin, in the Groin, that Hernia is called Enterocele, from the Greek Words v7eepv, which fignifies an Inteflin, and z4n, a Tumor. If the Skin is raifed by the Epiploon, it is called Epiplocele; and if the Tumor is made up of thofe two Parts, it is named Enteroepiplocele, &c. T HOSE Tumors arife from the Parts, which fall from their natural Place into other Places. A MONG thofe Parts, that can be difplaced, the firft to be found at the opening of the Belly, is the Eiploon, a fat Membrane, floating upon the Inteftins; afterwards the Intefiins, which feem to have no particular Limits: However, fome of them are fo ftrongly conceaed with the Peritonxum, that they can never leave their Place to form a Hernia. T H, Inteftins, that form thofe Sorts of Tumors, are the Jejunum, the Ilium, the Cxcumn, its Appendix, and the Colon. The Mefentery is frequently one of thofe Parts, and fometimes comprehended in the Tumor with the Inteftins. Laftly, the Bladder is alfo a Part, that can form a Hernia, as I fhall fay afterwards. THE Places, that make way for thofe different Parts, arc the Rings of the Abdominal Mufcles, the mechanical Struture whereof is very fingular, and hinders thofe Parts from coming out: For the ft Ring, reckoning from the Infide tp the Outfide, Operation of SU R G E R Y. 87 fide, is that of the tranfverfe Mufcle, which is not properly a Ring, as Anatomifts defcribe it, and the Cord of the fpermatic Veffels does not pafs thro' its flefhy Fibers, but direfly beneath the whole Mufcle towards the Ilia, as Mr. Petit fhew'd me feveral times. The fecond Ring is in the Obliquus internus, and in the flefhy Fibers of that Mufcle: It is fituated about one Inch lower than the other, and more towards the Symphyfis of the Pubes. The third is in the Obliquus externus, below the former, and in the Aponeurofis of that Mufcle: So that thofe three Rings defcribe an oblique Courfe, going from the Pubes to the Ilium. It appears from hence, that the Author of Nature has to framed the Openings of thofe Mufcles, that they are flopped by the Mufclcs themfelves. However, in fome Cafes, they come fo near one another, as I am going to fhew, that they make way for the Parts; but thofe Hernias are not fo frequent as the following. THE fecond Place through which the floating Parts of the Abdomen come out, is the Sinuofity of the Ilium, on which the Tendons of the Pfoas and Iliac Mufcles, and the crural Veffels defcend. That place is covered with a kind of Ligament, in the form of an Arch, made by the Aponeurofis of the Obliquus externus, which is refleded inwardly, as Mr. Duverney fays, to give Rife to the Obliquis internus; fo that by this Folding the Arch makes a greater Refiftance. It adheres to the fore and lower Spine of the Ilium, and proceeding from thence it adheres to the external Side of the 'Sinuofity of the Pubes, through which the tperniatick Veffels pafs. ITn that way, which is G about 88 A Treatife of the Sabout two Inches long, it leaves an oval Opening, which is only taken up, as I have juft now faid, with the Tendons of the RPfoa/ and Iliac Mufcles; and the crural Veffels, and is fhut up in the Infide by the mere Peritoneum, and covered in the Outfide only with the common Teguments, which are the Skin and the Fat. I think this Defcription clearly ihews how eafily the Parts of the Abdomen can pafs through the Opening, which is under the Arch of the crural Vefiels; and this is one of the moft frequent Herias. THOSE Hernias are not new: They frequently happen, efpccially to Women; becaufc the Rings of the epigafiric Mufclcs are finaller in them than in Men and if they arc not defcribed in Books, 'tis bccaufe no Care was taken to examine in dead Bodies the different Places of the Belly, which make way for the Parts that form the Hernia. THE third Place through which the floating Parts of the Abdomen come out, is the Ring of the Navel; bccaufe in that Place, the ProduCion of the Peritonium attending the umbilical Veffels, nothing remains but the internal Surface, which makes a leflfr Refiftance to the' Parts. I T is a little more difficult to underfland the ventral Hernias; bccaufe there are no other manifcft Openings, through which the Parts can come out; and bccaufe the Fibers of the epigafiric Mufclcs croffing one another upon the Sides, hinder the coming out of the Epiploon, or Inteftins; yet Experience teaches us that this happens fometimes: Learned Phyficians and Surgeons lave feen feveyal, Perfons affcecd with it and there was no Ground to afcribe it to any external Caufc. " " I j... -..', o " ** - J.... -, Operations of SU,R GER Y. 89 IF the Caufes of Hernias, which we have look, ed for in thofe Parts of the Abdomen, that can be difplacd, and in thofe Places through which they can come out, I fay, if thofe Caufes were not preceded by fome violent Efforts, attended with a Relaxation of thofe Parts, Man would ne7 yer be affeed with thofe fad Difeafes; fince the Author of Nature made the Vifcera loofe and wandring for no other Reafon, but that they might be toffed and thrown every way, in order to be always preffed by the Diaphragm and epigafirick Mufcles, for a more perfef Digeftion, and a more regular Diffribution of the Chyle. The Author of Nature made a Paffage in the Abdomen for no other Reafon, but to let out thofe Parts that are abfolutely neceffary for the Propagation of the Spccies. WHEN therefore any Hernia happens, there muff be fome concurring Caufes, which attending the former, produce jointly all the Diforders of a Flernia. THOSE Caufes are either internal or external: The former at upon the Parts capable of being difplaced, fuch as the Peritoneum, the Epiploon, the Inteflins, &ec. and are a fuperabundant Serofity proceeding from the Glands of the Intefti s, and Groins, and from thofe of the Peritoneum, which moiftening not only thofe Parts, but the Rings and Arches of the epigafric Mufcles, do fo relax their Texture, that they are forced to yield to the Impulfe of the floating Parts. ACCORDING to this Reafbning, Pcople who inhabit marihy and moift Countries, and live upon Dutter, Oil, and other fat andi unICtuous Alimpnts, are go 4A Treatifr of the are much more liable to Hernias; which is coni firmed by Experience. THE fecond Caufes a& upon the Parts, which occafion the Hernia, fuch as the Mufeles of Refpiration and of the Abdomen, and are violent Blows, great Concuffions, Vomitings, long Runnling, Burdens, Dancing, Leaping, continual Crying, a violent Cough, an Excefs in Venery, and generally all violent Exercifes. IN order to be informed of the Manner how the external Caufes occafion a Hernia, one muff know how the epigaifric Mufcles comprefs on all Sides the floating Parts of the Abdomen. Firft, the lower Fibers of the Ob/iquus externzis, for inIRance, on the right Side of the Belly, with the upper ones of the Qbliquus intermis on the other Side, do jointly form Lines cutting the Belly obliquely: And if the fame Application be made to the lower Fibers of the Ob/iquus externus on the left Side, and they be united with the upper ones of the Ob/iquus intermits on the right Side; it will appear by that wonderful Mechanifm, that the Belly is cut obliquely every way, and confequently compreffed in aUl the Parts of its Circumference. Secondly, Befides the Compreffion of tlf two oblique Mufeles, the Fibers whereof crofs one another, the* tranfverfe Mufele does alfo increafe that Aftion by Fibers ending horizontally in the Linea a/ba; and by that Mechanifm the Compreflionnis fill more exaa. THERE are fo many Circumftances to be mentioned, and fo many Mechanitins to be taken Notice of in Relation to thofe' Mufcles, that a particular Account of thcem all \vQild be too long; an( Operations of S R G E R Y. 91 and becaufe this belongs rather to Anatomy than to chirurgical Operations, my Defign is only tofhew the exad and equal Compreflion of the whole Circumference of the Belly. To make a right Application of this Theory; if the Parts difplaced are already relaxed, whatever be the Caufe of it, and if at that Time a Man happens to make fome confiderable Effort, the Di. aphragm being then violently contrated, as well as the Mufcles of the Abdomen, the Inteftins and the Epiploon will be fo compreffed on all Sides, that they muff in a Manner be forced to get into thofe Places of the Circumference of the Belly, which are the weakeft, the moft eafy to be forced, and make lefs Refiftance. IT is not difficult to apprehend, that in the fitrong Contration we fuppofe in the epigafiric Mufcles, their Openings will come near one another, and be fo parallel, that they will make but one Paffage in a ftrait Line, which not refifting fufficiently the Impulfe of the Inteftins, (the Peritoneum being fimple in that Place) they will get into that Paffage in the fame Manner as Dough fqueezed in the Hand, comes out through the Intervals of the Fingers, all the Mufcles of the Abdomen being then fitrongly contraaed. This happens the more eafily, becaufe the Veflcls of the Peritoneum arc conftri&ed in that Place, the Lymph diffufes it felf, and relaxes its Texture; which makes it yield the lefs Refiflance, tbecaufe that fame Violence obftruds the Courfe of the Liquors in the Rings of the Mufcles; and that Obltrufion makes them ftill more pliant and yielding to the Impulfe of the Intcflins. THE p A Treatife of the T HE crea Pofture of a Man does not a little contribute to thofe Difeafcs, fince the natural Dire&tion of the Inteftins is to fall perpendicularly upon thofe Places of the Belly, which refift the leaft. IF the Effort be not confiderable, and the Parts about the Groin are not much relaxed, the Inteftin or the Epiploon, being impelled through the Rings, will not go further than the Groin, and will occafion what we call a Bubonocele. But if the Effort be very confiderable, if the Skin and the Parts about the Groin are much relaxed, and if thofe that are come out, remain fo a long Time, they will by Degrees defcend into the Scrotum, and produce what we call a compleat Hernia. A ND becaufe the Heat of the Matter contained in the Inteftin, rarifies the Air, which does alfo get into it, the Inteftin will fwell, and comprefs its Blood-Veffels. That Compreflion obftruting the Circulation, there will happen an Inflammation in all the Parts contained in the Scrotum; which will facilitate the Adherence of the Inteftin both to the Tefticle and the Bag of the Hernia. The Inflammation, encreafing more and more, will affect the Ring of the Obliquus externtus; and a Conftrition will enfue, attended with fad Accidents, as I ihall fay by and by. LASTLY, the Inflammation, being ftill more encreafed, will heat to fuch a Degree the Matter contained in the Inteflin, that it will ferment very much, and confiderably diftend its Coats which will ftill increafe the Irritations, the Pains, and the Conftridion and this laft Accident obflruding the Return of the Blood, it will accumulate -,4 '" "' hin Operations of SURG ERY. 9 in the Coats of the Inteftin fo plentifully, that this Part will quickly be affeced with a Gangrene. Iv the Epploon is alfo fallen together with the Inteftin, the Accidents will not indeed be fo great at firft; but the fat Membrane receiving continually fome Blood from the Arteries, and the Return of that Liquid being flopped by reafon of the Conftrition, which begins, I fay, that Membrane will relax it felf more and more, and very much encreafe its Bulk. AND if all the Accidents juft now mentioned happen in the Inteftin, and if that Part of the Epiploon be encreafed to a confiderable Bulk, it will be fo confirained, both on account of the Inflammation and Conftrifion, that it will afterwards be gangrened. THE crural Hernia happens in the fame Man2 ner as that, which I have jug now defcribed, and even more eafily, fince the (ftacle is not fo great on the Side of the Arch, as on the Side of the Rings of the epigaftric Mufcles; and therefore I fhall fay no more of it. T H EExomphalous proceeds from the fame Caufes as all other Hernias I mean, that the Hole of the Navel will relax it felf, and grow larger as well as thofe of the Groin; and if at that Time one makes a great Effort, the Inteftins being impelled downwards by the Diaphragm, comprefled on all Sides by the epigaftric Mufcles, and befides meeting with fome Refiftance on the Side of the Groin, they will come out through the Hole of the Navel, whether a Woman's being with Child, or the Situation of the Intcftins, force them thro' that 94 ATreatife of the that Paffage; from whence different Accidents will enfue, according to the Greatnefs of the Difeafe. THOSE Hernias frequently happen to Children, becaufe a Tumor or an Inflammation is formed in the remaining Part of the Navel-firing, when it has been cut off' which occafions an Effufion of Serofity upon the Hole, and relaxes its Texture, that Hole not being yet well fhut up. I add, that Children crying continually, and lying frequently in a favourable Situation, the Inteftins are chiefly impelled that Way. WOMEN with Child are alfo much fubje6 to thofe Hernias, becaufe the Mufcles of the Abdomen being much ftretched, the umbilical Ring is forced to dilate it felf: And the great Bulk of the Womb, comprefling the Vcffels of the RPeritoneum and the Mufcles, caufes the Blood to ftagnate there; which relaxes them, (the Serum being feparated from them) and produces all the Kinds of Herniar, that happ, as I have faid, in the Interval of the Redti Adominis. IN order to explain the Hernias of the Belly, it is abfolutely neceffary to fuppofe that tome Fibers of the tranfverfe Mufcle are wanting, whatever Accident may be the Caufe of it, and that the Mufcles being in that Place weaker, and making lefs Refiftance to the Impulfe of the Inteftins, the latter moving by Degrees, will at laft get" into that defea6ive Part of the tranfverfe Mufcle, divide the Fibers of the oblique Mufcles, and raife the Skin. Thus the Hernias of the Belly will be formed. I Ihall fay nothing here of thofe Hernias of the Belly, which are a Confequence of Woundsd I have Operations of SuR GER Y. 9Y I have fufficiently enlarged upon that Subject, difcourfing of the Gajfrorhaphy; and I have faid that becaufe the RPeritoneum is feldom, or with great Difficulty re-united after a penetrating Wound, a Hernia does commonly attend fuch Wounds. THE diagnoflic Signs of thofe Difeafes are e-2 quivocal; yet when many of them concur toge-. ther, one may make a more certain Judgment, and know by what Part the Tumor is occafioned. I may further affirm, that fome Epiploceles have been attended with fuch fatal Accidents, that a Surgeon, before the Operation, might miflake it for an Enterocele. TH E Figure of the Tumur may ferve as an Indication; for if it be even and fmooth, if it has any Elafticity, and if the Impreffion of" the Finger does not remain in it, there is good ground to believe, that 'tis a Portion of the Inteftin, which begins already to fwill. I fuch Circumftances, the Surgeon muff ask the Patient how that Difeafe began; and if after fome violent Exercife, there was a fmall Tumor, which from that Time appeared and difappeared feveral Times, he may in fuch a Cafe pronounce it an Enterocele. A Pain in the Tumor, a fmall Colick, Vomiting, and a frequent Inclination of going to Stool, without voiding any thing, are further Signs of the Defcent of the Inteftin. AND if all thofe Accidents are attended with a Confitrition of the Ring, by reafon of its extraordinary Tenfion and Inflammation, the Pain will be much -greater; there will be a Fever, and a greater 96 A Treatife of the greater and almoft continual Vomiting i an'd all thofe bad Symptoms will encreafe the more, becaufe the Inflammation will grow worfe, both by the Irritation, and theMatters detained in the compreffed Inteftin. THERE are two Caufes of the Vomiting: The firft is the great Quantity of Matters in the Inteftins: They are at firft frothy; and the Patient fpits often, and is very careful to caft up thofe Matters; for they might enter into the Afpera Arteria, and ftifle him. As the Overflowing encreafes, the chylous Matters, and at laft the ftercoral ones fucceed the former. IRRITATION is the fccond Caufe of the Vomiting, which happens then fuddenly; and becaufe it is convulfive by reafon of the Pain, the greater the Pain is, the more frequent and violent will the Vomiting be. IN order to know whether the Ep loon only is the Caufe of the Tumor, the Signs appear quite contrary; and if we may believe Books, thofe Signs are fo true, that 'tis impoflible to make a falfe Judgment about that Tumor. They diftinguifl it by its Softnefs and Unevennefs. The Epploon, fay they, being a flabby and foft Membrane, its Defcent muft yield to the Impulfion of the Finger, and even its Impreflion ought to remain in it; and its fat Parts make it uneven. THOUGH all thofe Signs do frequently foretell an Epiplocele, and are grounded upon the Structure of the Part, yet they prove fometimes falfe. Mr. Chevalier, fworn Surgeon of Paris, heretofore Mafter of his Company, and Demonftrator of Anatomy and Surgery, did lately perform that Operation Operations of S tr R OPR Y. 7f Operation on a Woman, whofe Tumor was hafd,. finootli, and confiderably inflamed: The Patien6 had a great Fever, felt a violent Pain, and vomited continually. THE Surgeon, confidering all thofe Accident4; could nort but think that if Was a Tumor of,the Inteftin. He applied upon it a Cataplafmn, anct fome time after he perceived a fmall Flutiation, which was vety deep. At laft, the fame Accidents remaining ftill, he p'efformcd the Operation, and found only the Eiploon, under which there was m Abfcefs. The Patient is perfeJtly recovered. To go on with the Signs of the Ep ilocde, anothct Sign is to perceive a Tumdr in the Circumference of the Belly, which lafits for fome time without difappearing, and being much troublefome to the Patient: There is ground then td fufpett that the Epiploon is the only Caufe of the Difeafe. ANm if the Epiploon is a little ftraitened in th& Tumor, fox as numch as it adheres to the Bottont of the Stomach, it will pull it down-; whichi will occafion a fmall Hiccock: But if ain lnflain mation happens, if it be altered by aft Abfcefs; Or gangrened, there will be a Vormiting bccafioned by the pullihig down df the Stomach, br or the Corruption of the Epip loon, if at thd fame Time the Matters come out freely thiodgh the AtAs. Thefe Signs are alfo equivcicat; for' we hav&e feen one 6f the Cells of the Colon, pfndliedin a Tumor, as I flhall fay hereafter, which odccfioned a Vomiting; though the Matter continted t6 flow through the Anus. EH LAStLY; 98 A Treatife of the L A s r L Y, if in a Hernia, which is reduced from Time to Time, either by the different Situations of the Body, or by gentle Preflions, there remains thill fomething, and the Tumor does not appear to be lefs than one Half of what it wvas; it rmay be faid that the Inteftin and the Epi4lon togedter are the Caufe of the Difeafe. TH-E crural Hernias differ from the Inguinal in that the floating Parts of the Abdomen, whereby they are occafoned, pafs under a greater Arch, as I have faid, which makes a lefs Refiftance than the Ring of the Obliqpus externus, through which the Inguinal pafs. T H E fame Hernias are alfo different from the Inguinal with refpet to the Refiftance of the Ring of the Obliquus externus, that is neither relaxed, nor leffened by Remedies, or. by the moft favourable Situation, which fhould be a moderate Bending of the Thigh. And if it be objeted that Remedies, and fuclh a Situation do frequently very much contribute to the happy Succefs of that Difeafe I anfwver that thofe Remedies aating upon the Skin, and the Parts that are come out, muft needs be very good; and that if the Parts, which occafioned the Hernia, be reduced, it is rather becaufe their Bulk is leffened by the Remedies, than becaufe the Ring is grown larger by its Relaxation, fince its mechanical Strudure is coampofed of tendinous, tranfverfe, and longitudinal ribers, which form an Arch, the two Pillars whereof are affixed to the 'Pubes, and confequently it cannot be encreafed either by Poultices, or by the Situation. This Truth, for which I am indebted *... Operactiu0S of SU.R GR R1 Y. 99 indebted to Mr, Petit, wvill never be quiaioned by thofe, who have handled the diltfeting Knifpe AGAIN, the crural Hernias differ from the Inguinal in that they are more in the Fore-part of the Thigh, and direaly in the Fold of the Groin j which is the Reafon why the Surgeons, whol do not fuifficiently confider thofe.J ernias j miftake them for a Bu1bo, becaufe they pafs under, the Glands of the Groins, which in this Cafe are frc.quently fwelled. THE Prognoflics ought to be grounded upofl the Age of the Patient, and the Nature of thd Hernia. If a Surgeon attempts the Redudtion in a young Perfon, and if it fiucceeds, he may rely upon the Cure by ufing proper Bandages: But if the Patient be above thirty Years of Age, the Bandage will rather ferve to fupport the Hernia, than to cure it radically. WITH refpeda to the Hernia, if the Inteffin comes out alone, the Difeafe is more dangerous, and more or lefs fo, according to the Degree dot the Conftridtion. WHEN the Inteflin conies out with the p/ ploon, the Danger is neither fo urgent, 'nor f great, becaufe the Epiploon is a: foft Body, yhich ferves as a Quilt to the Intefitin, and preferves it in part from' the Compreflion of the Ringi ACcORDING to this Explication, we.may cafily infer that if the Epopboon be alone in the Her-. nia, it will be attended with fewer Ac;ients; and confequently that the Hernia will be the lealk dangerous. THE Hernias of the Belly are' lets dggotU than others: Thofe that take up the Interval.of H2;z " oo A Treattfe of the the- ReVi Abdominis, from the Navel to the Pubes, are moft of them incurable. WXHEN the Intefitn is gangrened, Surgeons do not.:advife to perform the Opecration;d for the Patients commonly die: But btcaufe we have feen aft Inftance of its good Succefs, if the Relations of the Patient defire it fhould be performed, he muff fair that Death is unavoidable without the Operation, and almoft. certain with it: Wherefore he fhall confult wife, learned, and prudent Surgeons. STH ` Amoft ufual diagnoftic Signs of the Gangrene afe the Alteration of the natural State of the!Tu'mor. For Inflance, it ought to be fome*hat faifed, and round, and have fome elafticity; for when the Inteffin is come out, fome Wind does always get into it; and' though the Confitriction be never fo little, that Wind, which is elaftick, diftends the Inteftin,. and produces in it fome Spring. the Skin ought not to change its Colour much, unlefs it inclines to red. Wherefore, if the Tumor be flat, foft, andA without any Spring, fo that the Impreflion of the Finger remains in it; if a confiderabic Alteration' happens in the Colour of the Skin, which is grown livid or blackifh, whereas before it was red; if the Patient feels no Pain iit that Part where the Tumor lies, and the other Accidents continue flill, fuch as: a Fever, Vomiting, &c,. if the Pulfe is denfe, and the Patient's Eyes look wild; all thofe Signs are plain Indicatiofns that the Part is gangrened, and the Patient in great Danger. SOME Surgeons, not fufficiently confldering the Accidents of thofe Tumiors, took' them for Bitubos, and opened vthem withCauflicks; a Remedy, whicly Operations of SURGER Y. Or which muff needs occafiolln a great Difordcrin thofe Parts. ADHERING Hernias are alfo very dapngerous, and give the Operator a great deal of Troubic. Mr. Petit cured onc, wherein the Bag of the C6 -cum adhered to the Scrotum. After ih had'fparated that Intcflin, it was in. a Manner excQrigted: He made the Dilatation at the Confiriction, and reduced the Inteftin into -the Belly, which flill adhered to the internal Circumference of the. Ring. In the following Drciffings, it appeared floating at the Orifice. LAs TLY, when the Inflammation is got into the internal Parts of the Belly, which may be known by its great Tenfidn, and by the Navel's rifing to a Point; thofe fad Accidents being attended with a hard Pulfe, the Surgeon njuft not in that Cafe appear very willing to perform the Operation; for the Succefs of it is very doubtful: And if he be earnei1y deftired to uidertake it, he muff give Notice to the Relations of the Patient that he defpairs of the Succcfs of the Operation, and undertakes it only to comply with their Defires. BEFORE I fpeak of the Cure of thofe Tumors, I muff fay fomething concerning the Hernias of the Bladder: Thofe Difeafes have been newly 4itl covered by Mr. Petit and Mr. Arnaud. T 11E Bladder is alfo one Part of the Belly liable to Hernias. That Difeafe ufually happens after a Supprefion of Urine, which, remaiuipg (p the Bladder, diltends it to uch a Degree, that it is forced to afccnd much above the 'Fubes; and the Urine encreafing more and more, an Inflammation er11es. H I TCs I o A Treatife of the T H E Bladder, being then preffed on all Sides; is forced to place it felf towards the Groins, and to contirat there fome Adherence with the adjacent Parts, i'n conftquence of its Inflammation. A "eat Belly is alfo frequently the Caufe of the THeri 'of the Bladder, becaufe the Womb, taking up at that Time the' whole Hypgafiriumm, and part of the Belly, preffs the Bladder much, and thereby produces two Accidents, which occafion fonmetimes one or two Hernias of the Bladder. T lE firfit of hofe Accidents is the Suppreflion of Urine, which happens only becaufe the Neck of the Bladder is preffed by the great Bulk of the Womb; and in confequence of that Suppreflion, it encreafts at laft to a confiderable Bignefs. T HE fecond of thofe Accidents is a Confequence of the Compreflion of the Bladder againft the PuIbes, whereby it is forced to lye on one Side, and to occafion afterwards a Hernia in that Place. Or the Womb compreffing the Bladder diredtly towards the Pubes, the Bladder is forced to lye on both Sides, and to reprefent, as it were, two Bladders; which occaflons two Hernias. THE natural Figure of the Bladder in Women is a further Confirmation of this Syftem, fince it is very different from that of Men. In Men, it reprefents a pyramidal Figure. But in Women, it is rather like a finall Barrel fituated tranfverfly, or like a Triangle, the Baflls whereof in the upper Part of the Os pubis forms two Angles; ind the Top of the Triangle is the Neck of the Bladder. TH E Bladder being placed between the two Membranes of the Peritonrum; and.the Bag, in the ufual Hernias, being made by the Relaxation of Operations of SURGERY. t3 of its internal Membrane; it ought to be inferred from that Strudure, that the Hernias of the Bladder never have any Bag. But if the Bladder defcends into the Scrotum, or into the Lips of the Womb in Women, it will carry along with it the internal Coat of the Peritonium, which coming near after it, will form in that Place a kind of Funnel, that will quickly be filled with the Inteftin and Epiploon. Therefore in fuch a Cafe there will be two Hernias, one of the Bladder, and the other of the Inteflin and Epiploon, if the latter be long enough; and thofe two Hernias will be fituated one by another, and diftinguifhcd by the Bag, which is that Funnel formed by the internal Coat of the Peritoneum, and which co. vers the Inteftin and the Epiploon. THE Signs, whereby we know the Hernias of the Bladder, are a Difficulty of making Water: the Patient voids part of the Urine, and quickly after he voids as much again. He places himfelf in different Situations, and is frequently obliged to prefs the Tumor, and raife it higher, that he may make Water more freely. ALL thofe different ways of voiding the Urine cannot be explained but by a Confiridion of the Bladder, which divides it, as it were, into two. As foon as the Patient has voided the firft Urine, he muft alter his Situation, or prcfs the fecond Tumor, in order to facilitate the Running of the Urine from that Tumor into the firft, and from thence unto the Urethra. W HI E N that Difeafe is attended with an Inflammation, either in the Bladder, or by reafoa of the Confrition of the Ring, all the Symptoms H4 of o104 ATreatfe of the pf the Nephretick Colick appear: But to avoid being impofed upon, one muft examine the Urines, which make thofe DifcafCs very different from one another. SOM E Surgeons, in order to be more certain of the FaQ, take care to probe the Patiect. That Pradic may be ufeful, when there is no Conflriction; but there is one, which, as I have jufi now faid, divides the Bladder into two, by forming a double Bag; the firfit ag, continuous to the Neck of the Bladder, will be very much diftended; and the ufual Probe, having but a fmall Space to move in, would continually run againft the internal Coat of the firfi Bladder, and might occafion in it 4ore dangerpus Accidpnts than thofe of the Hervia it felf. BESIDES, th fccond Bag, or that Portion of the Bladder, which makes the Tumor, could not be evacuated by the Probe, fince the Confiriflion hinders the PafT'age of the Urine from one Bag into the other; unlefs the Surgeon preferibes to the Patient certain CompreIlions, apd different Situ4 -tions, as I have already faid. HAVING defcrib'd Hernias, examined the Signs, whereby we may know their Nature and Differences, and givpn a particular Account of moft of thofe Accidents, which maýe thetp daigerous, I proceed to their Cure. SURGERY affqrds us two Ways of curing Hervias. In the firft Pjace, it direds us to a gentle Method, which our Authors have called Taxis, p;nd which we know by the Name of Redufion. gut if that Operation does not anfwer the Withes pf the Pjticnt pnd Surgeon, the Art of Surgery, 1o Operations of SURGER'Y. to5 Io necefifary to Men, affords feveral other Operations, whereby many Perfons have been preferved from Death. I fhall explain all thofe different Operations, beginning with the Taxis, or Redution. As foon as a Surgeon is fent for to eafe a Patient, affeted with a rccent Hernia, his only Defign muft be to reduce, if poflible, into the Cavity of the Belly, thofe Parts that are come out of it; but he ought to know firft what Sort of Hernia it is, that he may place the Patient in a proper Situation, and perform the Reduftion more eaftly, I it be an inguinal, or crural 1ernia, the Patient muft lie down upon his Bed lt4e, having his Buttocks raifed higher than the reft of the Body. The Surgeon, being on the Side of the affeted Part, muff bend p4 little the Thighs of the Patient, Ffpecially that of the affeced Side, and putting his right Arm underneath, (if the Hernia be on the right Side,) 1he muff handle the Tumor gently and a long Time, without puihing it towards the Ring: By that Means he may diffipate the Winds and Matters contained in it. Afterwards let him, with the fore and middle Fingers, draw 4 little the Tumor downwards, and endeavour to find the End of the Inteffin, that came out laff. All thofe Circumftances being duly obferved, the Surgeon flhall make an End of his Operation, by laying his left Hand upon the upper Part of the Tumor, above the Belly; and ufing the fore-Finger and Thumb, he fhall endeavour to reduce the Inteftin, as he pufhes it with the other Hand, beginning with that Part of the Inteftin, or Epiploon, which came out lait. If he canppot fucceed in that Manner, :ro 6' A 7reat~e of the xe, he iuff thave the Hair glowing upon the Tumoer, and its whole Circumference, and warmmly.anoint the Part with an Embrocation. Tere folldx1 thAt, wihich is commonly ufed in the Hozel-diteu at Paryi. Tb y take three or four Toeks.f Eggs, and fx or feven Ounces of Oil of Ro(~s, weellr mixed together, and warmed ipon aJflow ire: And thee they put into it a little Brandy; And.with that Embrocation they rub the Tumor, itS C uirtmiferenCe, and the Belly. But before thofe Refnedies be ufed, it is nior improper to blood the Patient in the Arm. This Caution is appro, ved by all learned Surgeons; it facilitates the Sucafrs of the Operation, by emptying the Veffels, and leffening the Inflammatioll. AFTERWARkDS the Surgeon applies upon the Tumor a refolving and emollient Poultice. That which is commonly made at the Hotel-/Diu, in Iiich Cafes, being approved by very great Surgeons, ought to be fet down here, as a good Remedy. T H E Operator takes emollient Herbs, fuch at Alallows, Mar/h-ma/lows, Mercurialis, the PcIlitory of the Wall, and the Violet-plant: He boils them in a fuffcient Xuantity of Water. Afterwards he f/rains them through a Sieve, and extrais the Pulp with a Spatula. In the next place, he diffolves that Pulp in the 7Decofion, and with that Mixture he dilutes fome Rice and Line-meal. He boils that Mixture w-ith a flow Fire, flirring it always; and whEn it has been one or twzo Hours upon the Fire, he adds to it common Honey and Vinegar, and boils again the JIThle at leaji half an Hour. Lajily, he judges that it is fiiciently boilcd, 6y the Smell of Operations of SURGERY. I of the Poultice, zwhich ought not to be like that of Meal; and before he takes it from the Fire, he adds to it fore Oil of Lillies, THAT Poultice has a very good Effet; but it requires great Care and Patience. Mr. Petit pretends, that when it is not well boiled, it does more Harm than Good. But becaufe that Poultice is a long time a boiling, and thePatient would not be cafed foon enough, the Surgeon, in the mean time makes another with the Crum of Bread. H E prcfcribes Clyfters made with a Pint of good warm Claret, and a Glafs of Walnut-Oil. Mr. Thibaut adds three or four Drams of Sugar, and fays they have a good Effed, efpecially after the Operation. If the Surgeon has a mind to make thofe Clyfters laxative, he puts into them common Honey, or Lenitives. THE next Clyfter is alfo very good, siz. A fuffcient Quantity of Milk, a Glafs of Wdatlrt oil, and Jome Cinamon. The Cinamon mufj be bruifed, and boiled in the Milk and then the Whole muff be firained, and the Oil added to it. WHEN the Poultice made with the Crum of Bread has been two or three Hours upon the Tumor, or, to fpeak more properly, till the firft Poultice be boiled, the Surgeon takes it off, and wipes his Fingers, and the Skin, which is fat and moift, that he may operate more fafely, and make again the fame Trials, for the Redufion of the Tumor. I F thofe Operations are ineffetual, the Surgeon muff apply the Poultice, which we fuppofe to be now boiled, and blood the Patient plentifully, according to his Strength; and if Phlebotomy proves ufclefs for the Redu&ion, the Operation,. which is the xog..4 ATreate of the the laft Remedy, will be more fuccefsful, and at. tended with fewer Accidents. Phlebotomy is the quickeft and beft Remedy we have in Surgery; but I never faw the good Effed of it in an Infiammation, unlefs it be very frequently repeated. Two Hours after, the Surgeon inuff take off the Poultice, wipe, as I have luff now faid, the Skin, and his Fingers, and attempt again the Redudtion. I F it be an inguinal Hernia, he mulf move the Parts towards the Bone of the Ilia, that he may follow the Courfe of the Rings: On the contrary, if it be a crural one, he moves them towards the middle of the Belly, or towards the Pubes; becaufe the Arch of the cruralVeftls is more turned that way: This is Mr. Petit's Method. If the Surgeon has not as yet fucceedec, he applies ftill upon the Tumor the fame Fomentation, and upon the Belly the Poultice, which he warms: He goes on with Phlebotomy and Clyiers. Laffly, if thofe Remedies prove ineffe'tual in four and twenty Hours, and the Accidents reo main 1ill, he muft proceed to the Operation. ' THE Surgeon ought to be very prudent in this Sort of Difeafes, and exprefs no Defire of performing the Operation, till he has endeavour'd to fucceed ip the Rcduaion. Thofe Timors muft only be handled by able Surgeons; becaufi if they do not iucceed, they do but make the Difeafe worfe tha it was. NOR muff a Surgeon infift upon curing the Tumor without performing the Operation; for bfonetimes h; fiuferS things to cop4 to that pafs, that wthWI Operations of S RG E R Y. to0 when there is no other Remedy left but the Operation, the Patient dies. Mr. Arnaud, and Mr. Thibaut were font fOt at the fame time to fee a Patient, who had a Bubo. nocele. The Tumor was round and raifed: They ufed the utmoft Care to facilitate the Redu&ion and being not able to fucceed in it after many Attempts, they advifed to perform the Operation. The Patient and his Relations were againft it, and fuffered themfelves to be deluded by an Empirick, who pretended to cure the Tumor, without opening it. After he had applied all his Remedies, and handled the Tumor a great many times, he could not fucceed in his Undertaking: Whereupon the Patient and his Friends had Recourfe to thofe illuftrious Surgeons, As foon as they faw that Tumor, they perceived a great Alteration in it. Whereas before it was round and raifed, they found it very flat, foft, and livid. Having well examined the Diforder occafioned by that Empirick, they acquainted the Patient and his Relations with a very fadt Prognoffick. However, being defired to perform the Operation, they went about it; and having opened the Bag of the Hernia, they found the Inteftin livid, and very black in one place. They reduced it into the Belly; and fooh after there came out of the Wound fome faeal Matters, whereby it appeared that the Inteftin Wias pierced: But thofe Matters coming out freely, there was ground to believe that the Orifice of the Inteftin was parallel to that of the Ring. That Ejeftion lafted about five and twenty or thirty Days, without any Extravafation in the Hypogaftrium, THoss 1o0.0A T7"eat /e of the TH os E Gentlemen, contirary to their Cuflom, did not put a Tent into the Wound, for fear of pufhing the pierced Inteffin into the Belly; but they only dreffed the Wound with tied Dozels. The Patient is perfe&ly recover'd, abating a fmall Fiflula, which remains, He carries Night and Day a Bandage made for that purpofe. A fmail Comprefs, dipt in Brandy, is laid upon the Fiflula, and the Bandage over it. The Comprefs is hardly flained in a Fortnight; which is a very inconfiderable Accident after fo great a Difeafe. T n I s Hifftory teaches us how dangerous it is to fuffer an Hernia to be handled by Men, who do not forefee the fad Confequences of it, and do not ufe the neceffary Cautions to prevent the Increafe of the Difeafe, whilft they pretend to cure it. I fhall make hereafter fome Reflcaions upon the Drefling, and draw iome Confequences from it. IF the Patient be affe&ted with an Exomphalous, the Surgeon muff begin with a gentle Method, as well as in crural and inguinal Hernias, and therefore he fhall place the Patient in a good Situation, which confifts in having the Buttocks and the Breaft fomewhat raifed. T HN4E Surgeonr fhall prefs the Tumor perpendi. cularly, contrary to the Bubonocele and the crural Hernia, as I have explained it; and if he cannot reduce the Inteflin, he fhall ufe the Fomentations and Poultices I have juff now defcribed, taking care to blood the Patient plentifully, and to give him Clyfiers. He muff repeat thofe Remedies, as well as in other Hernias, as often as he thinks fit. W H E N a Surgeon is fo happy as to fucceed in the Reduaion, he perceives it by the Noife, which the Opevati~ons OfSuR GIER Y a xr the Intefli*n inake s in being reduced. The Pain, which 'the Patient felt uinteTrncefs i the other Symptoms vanifh by dCegreC$. A FT ER this happy Succefs, the Surgeon nmu endeavour to fhiut up the Hole through which the Parts came out:, Wherefore he Ihall apply, in the place, where the Tumor' was, feveral graduated Comprefk-s, fuipported by the fame Bandage, which I ihall defcribe after the Operation'. THE Surgecon leaves that A"pparatuts a longer or fhiorter time, according as it grrows loofe. I have cured many Chi~ldren after that manner. IF the Patient be more advanced in Years, and has occafion to go about his aUfi~efs, thg Strgepq 141l put upion ~ after he hqs ufed for i6nec time the Bandage which I fh~dl deficribe, a SteelTrufs: These;are -forue of 4diffcrent Figures, acgor. ding, to the fever~al -Sorts QfHris: n f be;an Exom-ph!Qijs,, there pqght tQ be in, the Middle of its. Bojy, an Eminence. half-fphericJ wvhich exaffly ftops the place, throughi which the float~inga Parts opf The Abdomwn farwe out PHLEBOTOMY and ý Clyt1ers o~ghitpnot to b~v nwgletedi and. the Patient m-uff lie down., or fit ap right, fince the B~andage is mo1re rcaprgfýin-g in thofe Situations. Mr. Diornis fays in his Operg~os ia ~hp p~ens fometintegs that Chaildren have but -one Tea~j dcl in the 5Scrvotiww, and that the~ Te~fficle of th, pppofitte Side lies concealed in the Groij; Lb thar the Parctpe rivna fmnall Tiwior form4b it, fend for a Suirgo, takiig i6o.r This oughtw to; be arefuiy ýxWX~d-k fW Ur w09P4 ri A reati:f of the be a fad thing to perform upon a Tefficle the fame Operations, that are performed in a true Hernia. This- Obfervation appears to me very material. CHAP. Vi. Of the Operation of the Bubonocele, and the crural Hernia. TF the gentle Methods we have propofed, are infuflicient for the Redudion of Hernias, andct if the Symptoms continue to be urgent, the Surgeon muff open the Tumor; but becaufe that Operation is more or lefs dangerous, according td the Symptoms attending the Difeafe, a prudent Surgeon will not uideftake it, without a Confultation; that the Patient, and his Friends, may know what is to be feared or expe6ed frorn the Event. I am not ignorant that the Operation is always dangerous, and that the Patient is like to lofe hiS Life by it; But if the Surgeodn gdes about it in due time;j if the Patient be a Perfon of a go6d Con ftitution; if the Tumor has been handled by none but able Praditi'oners; if the patient has been pleni tifully blooded; if there be no Inflammation in the jifcera of the Abdomen, ( which may be knowni by a pretty regular Pulfe, by the Figure of the Ab; domen, wherein no Alteration will appear, chiefly by (the Figure of the Navel) one may very weP hoPe Operations of SUR GER Y.. 3 hope that the Operation will be attended with 4 good Succefs. To perforin that Operatioin miethliodically, the Patient muff in the firfit place make Water: The Ufefulnefs of this Advice is fo obvious, that I need not explain it. Afterwards the lick Perfon muff be placed in a proper Situation. He muft be brought to his Bed-fide, and laid down upon the 'Back: His Buttocks muft be raifed, and his Belly and Thighs covered with warm Napkins, folded double. T HEE Thi'gh of the affeaed Side being a little bended, to relax the Skin, the Surgeon flhall pinch it in the Tumor with his left-Hand, and a Servant fhall do the fame, and both of them together fhall raife it as much as they can. THE next thing is to cut the Skifi, which is upon the Middle of the Tumor, and which we fuppole to be raifed; but becaufe there are different Ways of ufing the Infirument, and the Incifons of different Hernias ought to be made 'differently, 1 ihall propofe fome RefIcLaions upon themn. I F it be an inguinal Hernia, the Openings of the Mufcles being brought near one another, and all of them together taking a perpendicular Courfe, the Incifion muff be longitudinal. But if it be i crural Hernia, the Arch of the crural Veffels 6eing fituated tranfverfly, and yet the external Branchi being fomewhat higher than the internal one,. the Incifion muft be made tranfVerfly, and fomewhat obliquely to follow the Diretion of the Groin. THERE are alfo, as I have juft now faid, difl ferent Ways of cutting the Skin. Some advife the uife of a ftrait Bjfouri, and to pierce the Skiri, by I stunitg 1 14 A 7eatife of the turning the Back of the Inftrument towards the Tumor. Others will have the Skin to be cut perpendicularly with the Edge of the Bif/ouri, putting the fore-Finger on the Back of it. I am willing to follow this laft Method, provided the Surgeon cuts only the Skin at firit, and a little of the fat Body.; and I take it to be preferable to all other Methods; becaufe the Surgeon fees what he cuts. BuvT if fome Accidents fhould diftend and inflame the Skin to fuch a degree, that it could not be pinched, as it happen'd in the Epiplocele, abovementioned, which was attended with an Abfcefs; in fuch a Cafe, the Operator fhould put the middle-Finger and Thumb on both Sides of the Tumor, and diffend the Skin tranfverfly, to cut it by a longitudinal Incifion. TH 1S Method ought to be ufed gently; and as ibon as the Surgeon perceives the fat Body, he muft quit the Biflouri, and take in the room of it a grooved Probe, and introduce it under the Skin; and he muff convey into the Groove of the Probe one Blade of blunt Sciffors to cut the Skin. He muff do the fame downwards, if this laft Inciifion was made upwards. W H E N the Skin in the Middle of the Tumor is cut longitudinally after one of thofe two Methods, the Surgeon takes with the Thumb and fore-Finger of one of his Hands the Lips of the Wound one after another; and with the fore-Fin. ger of the other Hand, he diffrets the Skin in the Circumference of the Tumor, efpecially in the upper and lower Part: Afterwards he conveys upon his Finger blunt Sciflars, to enlarge the Opening through Operations of S U R G F R Y. 1II through the Angles. This is Mr. Arnaudls Practice. TH E Surgeon enlarging that Incifion through the upper Angle, does fomctimes open an Artery, which emits Blood with great Violence. The Operator ought not to be uiirprifed at it5 for 'tis only a finall Artery, which lofes it felf upon the Fat, and in the Skin, and may eafily be flopped. T o go on with our Operation, the Surgeon muft cut and tear the Membranes, that cover the Bag: They are called Lamine. Mr. cDuverney fays, they are only finall fat Cells. Mr. Windlasw fays, that thofe fminall Membranes, which are between the fat Body and the Bag, are nothing but the cellulous Texture of the Peritonaum, which is very much encreafed by the Difeafe. But whether they be fmall Cells or Lamina, they ought to be cut and torn. I N order to cut thofe Mecmbranes or Lamnina~ I muft mak fcveral Obfecrvations. Firif, the Surgeon riift u e a Blifouri fomewhat crooked and very tharp; and itsBlade muff be faftened to the Handle with a Fillet. Though this Method differs from the Pra&ice of thofe, who make Ufe of Fleamcs1 yet it is very good, and approved by the greateft Mafters. Secondly, the Operator muff diffend thofe Membranes tranfverfly with the Thumb and fore-Finger, as it was praticed in the Skin, when I fuppofcd it to be inflamed; and by this Means the Surgeon has the Pleafure of feeing thofe Membranes contrad on each Side, as he cuts thcmi and befides he always fees what Progrefs the infirument makes. Thirdly, he muft lay the Jnftrumcnt almoft flat, (the Edge being turned to, I 2 wards x1 6 A Treatife of the wards the Tenis,) and cut the Membranes flanting: For if he ihould lay the Edge perpendicularly upon the Tumor, the Sight being confined at the Back of the Infrument, he might open the Bag and the Inteftin: Which would not be difficult, if the Hernia was dry, as it happens fometimes in inguinal Hernias and in this Cafe, a Surgeon ought to ufe all the Dexterity, which that Operation requires. Fourthly, he muft carefully obferve all the Veffels he difcovers, whether they be Veins or Arteries, to tie them in two Places before he cuts them; and by this Means he will perform the Operation almoft without any Effufion. The better to fucceed in this Particular, he muft have many Rags of Linnen, to wipe the Blood, as it appears. L A S T L Y, The fifth Obfervation confifs in pinching with the Fingers the fmall Membranes, that have been cut, to tear them on every Side; and when they make too great a Refiftance, the Surgeon drives underneath a grooved Probe, and conveying blunt Sciffars into its Groove, he cuts them. I F the Operator thinks he has difcovered the Bag by all thofe Means, he muft be fure of it by pinching the Bag with his Thumb and fore-Finger; and if he raifes then a membranous Part, he will be fully convinced of it. In this Cafe, he muft difcover the whole Bag, without opening it, and with its Help introduce a grooved Probe beyond the Conftridion, which he muft dilate, as I fhall fay hereafter, when I come to difcourfe of the compleat Hernia. THF Operations of S U R G E R Y. 117 THE Reader may already perceive, that I do not defign to treat of the Operations commonly performed in the Bag, as all Books and Surgeons do and we are indebted to Mr. Petit for the gentle and cafy way of performing thofe Operations, and the fafe and fpeedy Method of curing thofe Difeafcs. W HEN the Surgeon has difcoverd the whole Bag, and dilated the Conftricion, as I fhall fay in the next Chapter, Mr. Petit, a Man of a vaft Genius, and a great Pratitioner, advifes him to reduce the Parts contained in the Bag without opening it: Which is effeted by that excellent Operator in the following Manner. He takes the Bag with the fore-Fingers and Thumb by its Extremity the moft opposite to the Conftrition, and with certain circular Motions he reduces the Parts into the Belly. In the inguinal Hernias, he drives them towards the Bone of the Ilia, as I have already obferved; and in the crural ones, towards the Navel and the Pubes. As foon as the Reduction is over, he folds up the Bag, and puts it in the very Opening of the Conftrifion, and above it a fmall Cufhion of his own Contrivance. To make that Cuihion, the Surgeon takes a Piece of Linnen, which he cuts round, and fows in its Circumference, as if he had a Mind to make a Button. He draws the Thread by one of the Ends, having flopped the other; and the round Piece of Linnen fhuts, folding its felf like a Purfe. He puts into that Purfe fome Lint, and fome fmnall Rags worn out; and when it is filled up, he pulls the Thread more, and turns it round about, as if he was flopping a Button. I3 AFTERp S8 ATreatife of the AFTERWARDs he dips that Cufhion in a Mixture made of the White and Yolk of an Egg, to which he adds a little Brandy. He fqueezes that Cufhion, and having rolled it in his Hands to draw it out in Length, he applies it upon the Bag of the IHrnia and above it, as well as in its Circumference, he lays fome Rags and Dozels. He covers that Apparatus with three or four triangular Compreffes rifing to a confiderable Height, to prefs all the Parts; and he fupports the whole with the following Bandage, called the Spica. But before this, he muft ufe the Imbrocation, which I have already defcribed. Of the Spica of the Groin, for the Bubonocele. T o make that Bandage, the Surgeon takes a Roller, three Inches broad, and about thirty Feet long. He puts the End of the Roller upon the Side oppofite to the affeded Part, where a Servant holds it; and then he conveys the Head of the Roller upon the external and upper Part of the Thigh on the Side of the Operation, and behind, to come to the internal Part of the fame Thigh, in order to afcend upon its upper and fore-Part, where he croffes with the foregoing Convolution, to form a K in the Middle of the bending of the Groin. Afterwards he conveys the Roller to the oppofitc Side, paffing beyond the Body, and begins again the fame Circumvolutions juft now defcribcd, forming in the Groin an Edging, as he afcends, which makes the Spica, as I flall explain it, difcourfing of Bandages. But when he comes the third time to the external and upper Part of the Operations of S U R G E R Y. 19 the Thigh, he paffcs the Roller behind the Thigh, as I have already faid, to afcend to the internal Part of the Groin; and inftcad of crofling with the foregoing Convolution, to form a K, and make an End of the Sica, he faftens the Roller with Pins, turns it back, and pafkes again by the internal Part of the Thigh, to cover the Compreffes: Afterwards he conveys the Roller behind the Thigh, to come to its external and upper Part; from whence he conveys the Head of the Roller to the oppofite Side, to make an End of that Bandage with Circulars about the Body. TH is Method of reducing the Bag without opening it, though-new, will be very much approved for the time to come; and Operators mufft not fcruple to ufe it, fince the Inventor of it had no other Defign but to cure fpeedily, to operate fafcly, and to follow Nature Step by Step. She is a wife a Leader, by whom Phyficians and Surgeons ought to be direded; and fhe will never deceive them, if they take care to follow her Direitions. IN DEE D, if all the Methods I have propofed for the Redujlion, without -opening the Tumor, had been attended with the Succefs we expcecd from them; what would have become of that Bag? Would it not have been reduced with the other Parts? Or, would it not have remained in the opening of the Abdomen? We fee every Day that thofe Sorts of Redudions are not attended with any Accidents, and that they are cured immediately. TH E, Patient muff be nourifhed with Broth and Jelly: He muff take a Clyfler now and then; S'I 4. and 120 A Theatfe of the add the general Remedies ought to be preferibed according to the Accidents, that happen. C H- A P. VII. Of the Operatoon of the compleat Hernia. ACCORDING to the Doctrine, that is f now taught in the publick Schools, there are two Sorts of compleat Hernias. In the firift, the Tefticle is feparate from the Bag of the Hernia; and in the fecond, the Tefticle is confounded in that Bag with the Parts that make the Hernia. I fhall give a mechanical Explication of thofe Differences, when Icome to difeourfe of the Jlydrocele by effilffon. T o perform the Operation, the Surgeon muff place the Patient in the Situation mentioned by me, when I difcourfed of the Biubonocele, and take Care that he make Water, to empty the Bladder,,which might be pricked in dilating the Ring: This might be done more eafily flill in WVomen big with Child, becaufe the Womb, as I have fhewed, throws the Bladder upon the Sides. TH E Surgeon pinches the Skin, and cuts it according to the Lengith of the Tumor, as it's practiced in the Bubonocele. He alfo firetches the Membranes to cut and tear them. And if he will reduce the Hernia without opening the Bag, he Operations of S u r F R Y. 12 he lays it open in its whole Extent, and dilates the Conftrition, &c. THIS may be praficed in any Hernia whatfoever, (excepting the ventral Hernias, which attend a Wound,) provided the Bag be not fo large, and the Hernia fo old, that one may be fure, the Inteftin and Epifloon adhere to the Bag. I F the Operator thinks fit to open the Bag, as foon as he has difcovered it, he pinches it, as well as the Skin, and cuts it gently with a Biftouri; and immediately there comes out a limpid or ruddy Water, of which thofe Hernias are always full; which very much facilitates the Operation. H E introduces into that fmall Opening a grooved Probe, with which he raifes the Bag, to enlarge the Opening with Sciffors. Afterwards he puts the middle Finger into that Opening, that he may by that Means flide blunt Sciffors, in order to open the whole Bag. IF the Tefticle does not appear after that Opening, 'tis a Sign the Hernia is of the firft Kind, and that the Parts are only dccending as far as the Partition formed by the Tunica Vaginalis, as I fhall fay, when I come to difcourfe of the Hydrocele. The Surgeon muft then take great care of the Teltide, which lies hid under the Angles of the Bag, or even lower, and he muff particularly mind it, when he reduces the Intcftin; he muft alfo mind the fpermatick Veflels, for fear of conveying them into the Belly with the Inteftin, or compreffing them too much. ON the contrary, when the Tumor is opened in its whole Length, if the Surgeon perceives the Tefticle is confounded with the Inteftins, 'tis a Sign x12 A Treat;fe of the Sign the Hernia is of the fecond Kind; and there will be no need of fo much Caution, becaufe he always fees the Tefticle. AFTER the opening of the Hernia, the Surgeon muff reduce the Parts into the Belly; but becaufe feveral Obftacles hinder it, I fhall endeavour to remove them. THE firft Obitacle is the Conftricion of the Ring, which will no longer comprefs, when it is dilated. To remove it, a Servant muff raife the Ends of the Bag, and the Operator convey into the Ring a grooved Probe, clofed at the End, and then raife it to diftend the Ring, and remove it from the Inteftin. He muff take care to convey the Probe, rather on the Side of the internal Pillar of the Ring than of the external one, becaufe he goes farther from the epigaftrick Artery. THE Probe in that Situation is lometimes covered by the Swelling of the Intcftins, which hide the Groove of that Inftrument. A Servant muft then take the Inteftin on both Sides of the Probe; and to prevent having fo many Servants, Mr. Petit has contrived a Probe, which has in the Middle of its Body a Plate like a Heart: That Plate applying it felf upon the Inteftins, hinders them from covering the Groove of the Probe. Afterwards the Operator conveys a Biftouri fomewhat crooked into the Groove of that Probe, laying it near the Hand that holds the Probe, and at fome Diflance from the Parts that are to be cut, left he fhould commit fome Fault, if any body fliould pulh him. He conveys the Bifouri about two Lines beyond the Ring, the Point being always hid in the Groove of the Probe; and as Loon as it Operations of SUR G ER Y. 123 it has paffed the Ring, he lets down the Hand that holds it, bringing it near the Hand that holds the Probe 3 and by that fmall Motion the Point of the Bifouri leaves the Groove of the Probe, and makes a kind of Swipe whereby it is raifed up. THOSE two Inftruments remaining in that Situation, the Surgeon draws them all at once, moving the left Hand which holds the Probe, and bringing it towards the Ring that is to be cut. Such is the Method of dilating the Ring. THE Surgeon muff obferve, in the firft Place, to convey the Bifouri towards the internal Pillar of the Ring, as I have faid of the Probe: Secondly, to faften its Plate to the Handle with a Fillet: thirdly, to hold it with the right Hand, the Back in the Groove of the Probe, and the Handle in the Hand. Mr. Arnaud, in order to dilate the Ring, ufes a fmall Bi/touri, the Plate of which is commonly ihut up in the Probe. I mhall defcribe it, when I come to difcourfe of Inftruments. The Surgeon conveys it fide-ways under the Ring; and laying the Thumb upon its Spring, he raifes the Plate, which drawing the Inftrument, cuts the Ring. WHEN Mr. Thibaut performs that Operation, he conveys under the Ring a grooved Probe, blunt at the end, and making a Servant hold the Inteftin, he holds the Probe with the left Hand, and takes a ftrait Biftouri with the right Hand, in the fame manner as if it was a writing Pen; and conveying it with the Back in the Groove, he cuts the Ring with the Edge of the Inftrument: Afterwards he lets down the Probe and the Bifouri, and then draws 124 A Treat/fe of the draws them out. This Method appears to me likewife very good. Mr. Petit prefers his Biflouri (which I have defcribed, fpeaking of the Gajrorhaphy ) to all the Methods of dilating the Ring, and fays, it' may be conveyed into the Groove of the Probe, or without the Probe, and boldly driven, without being afraid of piercing or cutting any thing. He further fays, that Dilatation may be made with one of the Branches of blunt Sciflors. A s foon as the Dilatation of the Ring is made any of thefe Ways, Mr. Arnaud adviics the Surgeon to introduce the fore-Finger into the Opening, and to raife it towards the internal Part of the Mufcles, in order to know the Place where the epigaftric Artery lies; which may be known by its Pulfation: And when he has found it, he conveys the Finger a little fide-ways to avoid it, and then crooked Sciflbrs, blunt at both Ends, to enlarge the Opening. I F the Operator, in that Dilatation, has had the Misfortune to open the epigaftric Artery, he muff find out, as foon as poflible, the place that is opened; which lie will know, not by the Pulfation of the Artery (for an Artery never beats where it is opened, ) but becaufe the Blood will flop, when the Finger keeps it from coming out. THE great Quantity of Blood of that Artery proceeds from near the Ilia and the Surgeon ought to ufe his utmoft Endeavours to flop it, by putting two or three finall Rags upon the Opening, which a Servant ihall drive towards the Bone of Operations of SUR GER Y. 1 z of the Ilia, whilft the Operator makes an end of his Operation, as I am going to thew. AFTER all thofe Operations, the Parts, that make the Hernia, ought to be reduced; but a fecond Obftacle does frequently happen 3 and it muft be removed, as well as the firft, before the Surgeon goes about to reduce the Inteflin. This fecond Obftacle is too great a Quantity of Matters in the Inteftin, whereby it is fwelled to fuch a degree, that it cannot be reduced before they are reduced into the Belly: This muft be done by that part of the Inteftin, which is nearer the Anus. In order to it, the Surgeon muft draw a little that part of the Inteftin, which came out laft, that the Matters may have more room to be reduced. H E mut handle the Inteffin gently to divide the Matters, that have ftaonatcd in it; and if the Hernia is on the right Side, he muft drive them by degrees into that part of the Inteftin, which is neareft to the Ilia. 0 N the contrary, if it be on the left Side, the Matters muff be driven into that part of the Intcflin, which is overagainft the Anus; and then the Surgeon muff reduce them, beginning with the Part that came out laft, in the fame Manner as I have explained it, fpeaking of the Gaftrorhaphy. IF the Mefentery is come out, and confequently a great Quantity of Inteftins, the Operator muft begin with the Redution of the Mefentery, without which he would never be able to reduce the Inteflins. The following Hiftory will make the Readers fenfibic of the Importance of this Obfervation. x 6 A Teatife of the A Man who had been troubled with a complete Hernia for fome time, was kicked by a Horfe; and that Blow bruifed the Skin, and burft the higheft part of the Bag. The Inteftins came out of the Tumor plentifully, and occafioned a fecond Hernia, which reached to the Middle of the Thigh, and appeared as big as the Head. Mr. Petit tried feveral times to reduce the Parts into the Belly; but the Bag of the firft Tumor burfting, and having occafion'd by its Inflammation a Confirifion, which prevented the Redution of the Parts, all his Endeavours proved ufelefs. Wherefore he rcfolved upon the Operation 3 and after he had opened that large Tumor in its whole Length, he found no Bag in it, but a little Blood, and a great bulk of fwelled Inteflins, with a confiderable part of the Mefentery, which were come out thro' the Gap of the Bag of the firft Hernia. T H A Length of Inteflins was only covered with the Skin and Fat; and Mr. Petit conveying his Finger towards the Conftrition, which was only in the torn part of the Bag, did not find it very confiderable: However he cut it upon his Finger with crooked Sciffors, and went about to reduce the Inteftins into the Belly. They were fo much fwelled, that when he had reduced a fmall part of them; they came out again immediately. At laft, he had a mind to pierce them with a Needle, that the Wind might come out; but having attempted to reduce a fmall part of the Mefentery, the Inteftins that followed it, did not come out again; by that means the reft of the 0 -peration was very much facilitated. The Patient was Operaions of SuRG ER Y. I27 was plentifully blooded: He took feveral Clyfters, kept to a fire. Diet, and recover'd his Health. IT appears from this Obfervation, that when the Mefcntery comes out, the Surgeon muff reduce it, and immediately after, that part of the Inreffin, which adheres to it, and fo on, till the Whole be rcduced. LET us refume our Operation, and take Notice of a third Obftacle to the Redudion of the Parts, which are the Caufe of a Hernia; I mean the Adherence of the Inteffin, or Ept/loon to the Lag, or to thc Tefticle; or of thofe two Parts together. IN order to remove this Obflacle, it is abfolutely neceffary to diffelt the Parts, and divide them from their Adhefion. But if the Adherence be in the Inteflin, it muff be diflthfcd in fuch a manner as not to be damaged. If the Adherence be in the Epiploon, and it adheres to the Tefticle, the Epz/loon muft be cut, and the Tcflicle left untouch'd. L A S T L Y, if the Intetlin adheres to the Teifticle, moft Authors are for Caftration. I would rather feparate them, preferving alvways the Inteflin whole, and favfing as much of the Teflicle as poffible: I am perfuaded, it might be cured by a careful Drefing. DID not Mr. Arnaud frequently open an Abfcefs in the very Body of the Tethiclc, which was well cured? Why thould it be impolfible to cure a Wound made in that Part by a cutting Intrument? I1F S18 A Treat;/ of the IF the Surgeon perceives that the Epiploon is grown larger, he mut make a Ligature in it, and extirpate it in the fame manner as I have explained in the Chapter of the Gafirorhaphy. LASTL Y, if the Operator has cut the Inteftin, by opening the Bag, he ought to make in it the Skinner's Suture, as I have dcfcribcd it in the Ga. flrorhaphy and that Suture may have a better Succefs than in the Wounds of the Abdomen, fnce the Matter does naturally come out of that Cavity. LASTLY, In this Operation, as in all others, the Surgeon muft have fmall Rags to wipe the Blood, and to perform a drier Operation; and for the fame Reafon, he muff make a Stitch in all the fmall Veflels, that are troublefome during the Operation. WHAT remains is to apply the Apparatus, about the firft part of which Operators are not agreed. Some, and among them Mr. Mery, Mr. Arnaud, and Mr. Thibaut, ufe a Linnen-Tent very long, to keep the Openings of the Mufcles always open, and parallel to each other, in order to give an Iffue to the Serofities that are in the Belly. O T H E R S, fiding with Mr. Petit, are altogether againft the Ufe of that Tent. They fay, that Method does very much retard the Cure, and occafions the communication of the outward Air with the inward; which may be attended with fad Confequences. Mr. Arnaud confirms his Praffice by an Experiment he made at Park upon a Woman, who had undergone the Operation of the Bubonocele. Having ufed two or three times a very long Tent, he Operati;ons of SU R GER i. i* he was obliged to go into the Country, and defi red a Surgeon to take care of that Woman in his Abfence. When he came to Town again, hd found the Patient in a much Worfe Condition. Her Belly was prodigioufly diftended and fwelld d ihe felt very fharp Pains, and had a violent Fevet4 He took off the Dreffing, and found it very dry$ having but one very fhort Tent. He convey'd his Finger into the Wound, and perceived that the Ring of the Obliquus internus was flopped. He removed that Obitacle with his Finger, and got into the Belly: There came out immediately a flink. ing Matter niix'd with Blood; and having put A Tent into the Orifice, the Acciderits vanifh'd the next Day, and the Dreffing was nmoif. THAT Surgeon adds to this Experiment anr A'r gument, which confitms the happy Succefs of that Difeafe, and the Confequences that may be drawn from it according to his Syftem. HE fays, the Peritontum and the Inteftins rdo attended with a vaft Number of fmall Glands,whiclh being compreffed by the Efforts that occaftoned the Difeafe, have difcharged a Serum, which falling into the Belly, ferments, and is the Caufe of many Accidents like thofe juft now mention'di He further fays, that the only Way of curing the Difeafe, is to give an Iffue to that Serums without which it contrafts fich an Alteration, that it gangrenes all the Vifcera, and Death will unavoil dably follow. I confefs, this Argument, confirrried by bxpeE tience, is very firong; and upon this Occafioni itf was given in order to prefrve the Patient's Lifer Iut it may be faid, that the fad Accidents, which K happned x30 A Treatife of the happened to her, were occafioned by the Surgeon, who wiped the Wound too carefully, and made it bleed in its whole Circumference: And the Wound being all the while expofed to the Air, which perhaps was very cold, the Orifices of all the fmall Veflels did contra&, and the Blood being. coagulated in them, there happened an Inflammation, which occafioned the Pain, the Tenfion of the Belly, and a Fever; andthofe fad Symptoms would have brought the Patient to her Grave, had it not been for Mr. Arnaud, who removed the Obflacle by difcharging thofe Veffels. BE SID E S, it may further be faid, that the Lymph filtrated by the Glands of the Peritoneum, and Inteftins, is a very ufcful Secretion, and ferves to mnoiftcn all the Vifcera, that they may gently flide one upon another, and not be irritated by their Fricion: And though it be feparated by fome Efforts, in a greater Quantity than ufually, yet it will not contrad a greater Malignity, but it will be carried off by the abforbing Glands, that are in all the Parts, and by the Vefl7els themfelves. Wherefore that SeMum will occafion no Diforder, unlefs it has been altered by the Air. A G A I N, Don't we fee Dropfies, the Water of which might more e'. occafion Diforders, that are perfedly cured, whout the Help of the aParacentefis? Becaufe "that Serum is refumed by the abforbing Glands, driven by Stool and Urine, and fucked in by the Veffels. N AY, the Experience of thofe, who approve the Tent, ihews that it is not neceffary to cure that Sort of Difeafe; and if the Thing be narrowly enquired into, it will appear by that very Experience that the Tent is hurtful, I Operation of S u R ER t. 3 t I have fet down in the foregoing Chapter thd Hiftory of the Bubonocele cured by Mr. Arnaud and Mr. Thibaut; and I have faid that the Feces coming out through the Wound, made them apprehenfive that a long Tent (which would have opened a Paffage to the Serum, from whence the Diforder muff proceed) would have driven the pierced Inteffin into the Belly, and occafioned the Fall of thofe fame Matters into that Cavity. Which is the Reafon why they were contented to put into the Wound tied Dozels 3 and yet it was cured. IF the Lymph, feparated by the Glands of the Peritonaum and Inteftins, had occafioned the Accidents, which happened to the Woman abovementioned, and if that Lymph had the fame Effe&t in all tick Perfons, unlefs it was evacuated through a Paffage kept open for that Purpofe, thofe Gentlemen would not have been fo fuccefsful in that Operation, fince the Tent was an Obftacle to the Cure. To confirm my Opinion, and fhew, that the Tent is not only ufelefs in many Cafes, but alfo fometimes hurtful, I fhall fet down the Hiflory of a Cure performed by Mr. Mery in the Hotel-tDieu at Paris. THE 7th of November 17 3. he performed thd Operation of the Bubonocele upon a young Man of Eighteen or Twenty Years of Age, who had been troubled with that Difeafe two Days. The Bag being opened, he found that the Tefticle was confounded with the Inteftins, and that it was in the Ring of the Obliquus externus; whether it had afcended by reafon of the Inflammation, or was there originally, K x TTat 132 A Treatife of the T H E Reduction of the Inteftins being over, Mr' lery fays, that if a long Tent had been put in to keep up the Opening of the three Rings, it would have compreffed the Tefticle to fuch a Degree, that not only an Inflammation, attended with fad Accidents, would have enfued in that Part, but alfo it would have grown lean and deftitute of Nourifhment, and at laft it would have been wholly feparated. To avoid all thofe Symptoms, he put into the Wound fome Dozels,&c. The Patient did perfedly recover in four Weeks. THESE two Inflances flhew therefore, even by the Experience of thofe Surgeons, who ufe a Tent, that it was hurtful in thofe Cafes. And fince the Patients did quickly recover without its Help, and there was no confiderable Tenfion in the Abdomen, nor any violent Pain, or Fever, it appears that thofe Accidents do not proceed from the Lymph of the Glands of the 'eritonaum and Inteftins, detained in that Capacity. Therefore, according to the fame Experiments a long Tent is ufclcfs. LAST May 1718, I faw a crural Hernia of a Woman, the Operation of which had been made by Mr. Petit, without opening the Bag: He only made ufe of his Cufhion; and the Patient, tho' advanc'd in Years, was well cured in eighteen Days, without any Accident. LASTLY, here follows another Argument, which is unanfwerable. If the Serum, fcparated by the Glands of the Peritoneum and Inteflins, by reafon of violent Efforts, fuch as Vomiting, and others that attend Hernias wxith a Conflri&ion; if that Serum, I fay, was the Caufe of the faid Accidents, which fomnetimes follow that Operation, by beu.a ~ Operations of SURGER Y. 133 ing detained in the Belly, for want of a Tent to keep the Paffage open, how fllall we explain the frequent Succef' of the TaxU? What will become of the Serum in a like Cafe? T s Obfervation, which appears to me unanfwerable, was imparted to me by Mr. Verdier, one of the great Anatomifts of our Time, I fliould here beftow upon that excellent Surgeon the Praiies he deferves i but the particular Effeem, which all the Learned exprefs for his uncommon Merit, and the great Obligations he has laid upon young Surgeons, are above whatever I could fay of him. WHEN the epigafiric Artery is opened, by applying the Apparatus, the Operator mufft lay upon that Artery a tied Dozel dipt in Stiptic Water, and drive it towards the Outfide. Afterwards he fhall put into the Ring of the Obliquus externus Mr. Petit's Cufhion dipt in a proper Medicament, and roll it a little in his Hands to fqueeze the Liquor, that it may be fomewhat oblong. He lays above it fome Dozels, and fills the whole Scrotum with them, or with fmall Rags, and puts upon that whole Apparatus three or four graduated Conmpreffcs, which have a wonderful Effea. He makes an Embrocation upon the Belly, Groins, and the Scrotum; and then he covers the Belly with Conmpreffes imbibed with the fame, and lays upon them a large dry Comprefs, to faften the Pins more eafily. He raifes the Scrotum with a Comprefs like a Sufpenfor, and keeps up the Whole with the following Bandage. THE Bandage proper fo.r the Operation of the complete Hernia, is the Spica of the Groin, which I have defcribed for the Bubonocelek only with K 3 this 3 4 A Treatife of the this Difference, that the Roller ought to be three or fix Feet longer and when the Surgeon has made the three Turnings of the Roller, which form the Spica, and turned over the Roller to cover the Compreffes, and is defcended to the internal Part of the Thigh to begin the Circulars about the Body, he ties the Roller with Pins in the Groin of the fick Side: Afterwards he conveys it to deSfcend under the Scrotum, and afcend again to the oppofite Groin, where he pins the Roller: He afcends again to pafs in the fame manner under the Scrotum, forming an Edging, and ties it in the Groin of the affected Side, to end with Circulars round the Body. PHLEBOTOMY, Clyfters, and a very ftriat Courfe of Diet, ought to be obferved, as in the Bubo, nocele. CHAP. VIII. Of the Operation of the EXOMPHALOS and ventral HERNIAS. W HEN the Attempts for the Redution of Sthe Parts, that are come out, prove ufelefs, and the Accidents continue very dangerous, the 0 -peration ought to be performed: It confifts in opening the Tumor, and reducing the Parts into the Belly. ALL the Books advife us to make a longitudinal Incifion upon the Tumor. Mr. etit makes Si Operations of SuR GEFRR Y. 3 a crucial Incifion with a flrait and fharp Biflouri, the Blade of which is faflened to the Handle with a Fillet. THE Surgeon pinches the Skin at firit, if he can do it: If not, he makes a tranfverfe Incifion upon the whole Tumor, taking care to cut only the Skin, and a little of the Fat; and then he makes a longitudinal Setion, whereby the Incifion becomes crucial. AFTERWARDS he turns back the four Angles of that Wound, and dilates it with his Fingers. In the next place, he perceives a Net, which is frequently miffaken for the Inteftin: He mufl cut it with a crooked and fharp Bi/beuri, the Blade of which is faftened to the Handle with a Fillet. When he cuts the Net, he muft ufe all the Caution and Care above-mentioned to cut the membranous Cells of the other HIrnias, and tear the Net as much as he can. As foon as he has deftroyed it, he will perceive the Bag, which he muft raife a little, to make a fmall incifion in it with a Biflouri, or Sciflors. Mr. Arnaud obferves, that in thofe Sorts of Tumors, there is always fome Serum in the Bag; which is a certain Sign that it has been opened. The fame Advantage does not always happen in the Bubonoceles; for I hlave faid that thofe Tumors were fometimes dry, THE Operator conveys the fore or middle-Finger of his left-Hand into the Opening, which he has made in the Bag; and with the Help of that Finger he cuts it crucially with crooked and blunt Sciffors. WHEN the Surgeon opens the Bag, he may, acK 4 cording 136 4A Treatife of the fording to the Doctrine and Experience of Mr. Arx Vaud, make a good or bad Prognoftick about that Difeafe. For inflance, if he perceives that the Epi0 ploon is confined to the Circumference of the Ring, 'tis a good Sign, and he has good ground to believe the Patient will recover: Whereas if the Epiploon is come out into the Bag, without contra&ing any Adherence to the Ring, and is very much incrcafed, as it generally happens, the Patient will be in a defperate Condition; for if the Epfploon be put again into the Belly, it will by its Weight prefs the Inteftins very much, and occafton fuch Accidents as will put an end to the Patient's Life, If it be cut, the Accidents will be the fame as thofe, which I have mentioned in the Gadfrorhaply If the Hernia be old, and a great Portion of the Itecflins is come out, the other Vifcera having more Room in the Capacity of the Abdomen, will extend themfelves, and fill up the Vacuity occafioned by the coming out of the Inteftins. And if thofe Parts are put again into the Belly, their natural Place being taken'up by the good Plight of the other Parts, all the P/ifcera will be fo crowded, that the fame Accidents will return foon after, and be quickly attended with Death, as it will appear by the following Hiftory. Mr. Arnaud has feen Exomphalos's of feveral figures, and fome among others in Women, which took up a great Space, and were not unlike the Figure of a large Cheefe. Thofe Women could not go to ftool but by rubbing their Belly, and handling their Tumor a long time. It happened that one of them could not eafe her felf by that means; and the Suppreffion of the fecal Matters was attended with Operat;ons of SURGERY. 137 with a violent Vomiting. Mr. Arnaud refolved upon the Operation: Having opened the Bag, he perceived in it a large Bulk of Inteftins, and obfcrving fome Ligaments, he inferred that they were thofe of the Colon, which adhered to the upper part of the Tumor. The Reduation was well made; and though the Operation prov'd very fuccefsful, and the Surgeon had obtained whatever he could defire in fuch a Cafe, which was to make the Pa' tient go to Stool, and put an end to the Vomiting, yet the Accidents began again, and the Patient died on the fifth Day. I T appears by this Obfervation, that my Confequence is grounded upon Reafon and Experience. To return to our Operation, the Surgeon muft diffe& and take off all the Adherences, obferving the Circumftances fo frequently mention'd by me, and remove all the Excrefcences, if there are any, whether they be fat or flefhy. Laftly, he muff put again the Parts into the Belly; but in order to it, he muff deftroy all the Adherences, which prevent their going in. STo that End, let him ufe Mr. Petit's BifJouri, which I have already mentioned feveral times, and exafly defcribed, and let him convey it, without any Fear, perpendicularly into the Belly: Or elfe, let him ufe Mr. Arnaud's Method, which confifts in putting the fore-Finger into the Ring, where generally the Inflammation is not fo confiderable as to prevent the Introdution of the Finger. 'Afterwards, the Surgeon, in order to cut that Ring, flides, with the Help of that Finger, crooked, blunt, and very large Sciffors; for fmall Sciffors could not cut the Teguments together with the Ring. LASTLY, t38 3A Treatfie of the LASTLY, if the Inflammation was fo great, that the Surgeon could not introduce his Finger into the Ring, by reafon of its being very much ftraitened, and if lie had not Mr. Petit's Bifouri, he muft dilate the Ring with the grooved Probe, and the crooked iBftouri, as I have faid, when I difcourfed of the JGafrorhaphy. THE Queftion is to know, in what Part of the Circumference of the Ring that Dilatation ought to be made. Some modern Authors fay nothing of it, and others prefer one Side to the other. IT ought not to be made on the right Side towards the Diaphragm,.fay fome Authors becaufe the Operator would certainly cut the umbilical Vein, which reaches from the Ring to the Fiflre of the Liver. It ought not to be made neither in defcending towards the Groins; becaufe the Surgeon would run the hazard of cutting the umbilical Artery, which proceeds from the external Iliack, and pafles through the umbilical Ring. The Dilatation ought therefore to be made on the left Side, towards the Diaphragm; becaufe in that Place there is no Part that can occafton any Diforder. IT feems to me, that an Objeaion is already raifed againft that Method,by faying that the umbilicalVeins and Arteries, become, after the Birth of the Child, fo many Ligaments, the Sedion whereof would not be very prejudicial to the Patient. (Tho' a modern Author affirms, that if the umbilical Vein was cut, the Liver would be no longer fufpended, and that the Vena cava being compreffed by it, and the Circulation of the Blood interrupted, Death would immediately follow.) That Objedion is well grounded: Yet it may be faid, that Nature does frequently vary, efpe Operations of SURGERY. 39 efpecially in the Veffels, and that it may happen that the Velfels preferve their Courfe, and contain fome Blood, as Mr. le Dran, Jun. f worn Surgeon of Paris, affirms he faw it in a Lady, who ftirring herfelffobmewhat hard, felt a Ruption in the Ring; and immediately he perceived an Hemorrhage: From whence the Surgeons inferred, it could only proceed from the umbilical Artery, which had preferved its Courfe, and contained fome Blood. THE Readers will more eafily apprehend what I have juft now faid, when they know that Mr. Daverny has publickly demonfirated that the umbilical Arteries do always preferve their Orifices to the Bottom of the Bladder, to which they afford feveral Branches. IF the Bulk of that Hernia is not very great, the Operator may, as in all other Hernias, lay open. the whole Bag, dilate the Ring, and make the Re, dution without opening the Bag. THE next Thing is to re-unite the Wound; which cannot be effeted by following the Method to be found in Books becaufe all the Authors, with an unanimous Confent, advife us to put into the Ring a hard and long Tent, faftened to a Thread, to prevent, fay they, the coming our of the Parts, and to give an Ififue to the Matter. I have confuted that Argument, when I difcourfed of the Gafirorbaphy, and ihall only fay in relation to the Exomphalos, that all the modern Pratitioners difapprove the Scarifications in the Circumference of the Ring, prefcribed in many Books, and wholly rejet the Suture. MR. Petit applies dircaly upon the Ring his Cuflion, which' muft be faftened to a Thread; and 140 40A Treat~ of the and the next Day the Surgeon has much ado to draw it out, becaufe it flicks both to the Angles of the Wound and the Ring; and when it is out, the opening of the Belly difappears. Afterwards he fills the Wound with fmall Rags and Dozels. He makes upon the Belly the Embrocation, which I have mentioned, fpeaking of the other Hernias. He covers the Drefling with three or four graduated Comprefles, and keeps up the whole with the Napkin and Scapulary, which I have exaftly defcribed, difcourfing of the Wounds of the Abdomen. MR. Arnaud, and Mr. Le Dran, fworn Surgeon of Paris, heretofore Mafter of his Company, and Surgeon Major of the French Guards, performed the Operation of the Exomphalos upon a Perfon, who voided the fecal Matters through the Mouth, and fome came out alfo through the Anus; which made the Operators believe that the Hernia was occafioned by the Epiploon. The Bag being opened, they found in the Ring a fmall Cell of the Colon; fo that the Inteftin not being wholly engaged in the Hernia, the Matters might ftill pafs from time to time, and therefore they came out now and then through the Anus. But becaufe they were fornetimes heaped up in that Place, they were forced to afcend; which produced the Vomiting. And the Concuffion of the whole Body, occafioned by that Vomiting, did fo fhake that Heap of Matters, that being compreffed on all Sides, it was forced to pafs downwards for fome Time. PHLEBOTOMY muff not be negleaed upon this Occafion: The Surgeon muft prcfcribe frequent Operations of SURGE RY. 141 quent Clyfters, and a very ftrif Courfe of Diet, viz. good Broth, and fome Spoonfuls of Jelly, if it be thought proper. THE ventral Hernias, whether they be occafioned by the Relaxation or Rupture of fome Fibers of the epigaftrick Mufcles, or fucceed the Wounds of the Abdomen, require alfo the Operation, when the general Remedies and the Taxis prove ineffedual, and when Vomiting and the other Accidents continue. To perform that Operation, the Surgeon brings the Patient to the Edge of the Bed, and having laid him down upon the Side oppofite to the Hernia, he pinches the Skin upon the Tumor, and cuts it, as is pradifed in the other Hernias. Afterwards he lays open the whole Bag, dilates the Conftrition, and reduces the Parts and then he dreffes the Wound. A Shoemaker of Parsw, whofe Name was Petit, felt all of a fudden a very violent Pain under his Belly; and almoft at the fame Time he was troubled with a great Vomiting. His Surgeon knew the Difeafe, and perceived above the Arch Of the crural Veffels a Tumor, not bigger than a fmall Nut, and very hard and painful. He faid, it was a Hernia, and the Operation fhould be performed. The Patient and his Friends, being difpleafed with that Prefcription, made their Application to a Quack, who flighted the Surgeon's O-. pinion, and advifed an Emetick. To put an End to thofe Differences, Mr. Petit was fent for: Having examined the Difeafe, he very much approved what the Surgeon had laid, and performed the Operationa 142 A Treat~ of the H E made an Incifion upon the Tumor, and laid open the whole Bag, without opening it. Afterwards he dilated the Conftridion. The Wound was quickly re-united, and the Patient cured in five Days. THE Hernias, which happen after a Wound, can' not be cured, as I have already faid, by that excellent Way of operating, fince thofe Sorts of Tumors have no Bag, it being very difficult to re-unite the Peritonaum after a Wound penetrating into the Abdomen; which has been confirmed a great many Times by opening dead Bodies. Wherefore, when a Surgeon is obliged to perform the Operation by reafon of fome dangerous Accidents, he ought to do it warily, and expe to find fome Intcftins under the Skin and the Flat. H E muff try all the Ways of making the Re". duaion by the Taxis, fince the Operation is attended with a Relapfe. Which way foever the Patient be cured, he muft never be without a. Bandage. CHAP. IX. Of the Dropfy in relation to the Paracentefis. SY aDroapfr of the Abdomen we mean an exd traordinary Tenflon of that Part, occafioned by Waters extravafated in its Cavity, and attended with a Swelling of the Legs and Scrotum. EXPERIENCI Operations of S R G R Y. '43 EXPERIEN CE teaches us that crude and undigefted Aliments, cold and acid Liquors, fix and coagulate the Blood to fuch a Degree, that the Serum fcparates from it, and produces a Dropfy. But becaufe that Dropfy is general, and that which I am difcourfing of in relation to the chirurgical Operations proper for the Abdomen or its Circumference, is particular; I hiall enquire into the Caufes of the Water gathered in the Abdomen. I the Vena Cava of a Dog be tied above the Iliack Veins, it appears that the Parts under the Ligature become dropfical. Therefore, the Dropfy in this Cafe is only occafioned, becaufe the Blood of thofe Parts being ftopped, the Serum, contained in that Liquor, feparates from it, gathers in one Place, or is infiltrated in the fatty Cells, and produces that Difeafe. AND indeed, all the learned Phyficians, who have explained the Differences of that Difeafc, have found, by opening dead Bodies, fome Tu. mors whereby the Veins were fo compreffed, that the Blood could not at all, or hardly, go farther. Wherefore, according to thofe Obfervations, the Dropfy of the Abdomen will happen, when fome of its Parts, or Vifcera, are fwelled. THE Blood being flopped in the Veins by the Compreflion of fome fwelled Parts, or Vifcera, of the Abdomen, and not being able to continue its Courfe by reafon of that Compreflion; it will neceffarily very much dilate the Veins, wherein it is contained. THE Veins being thus dilated, the feveral ibers, which compofe their Membranes, muff needs recede from one another* apd leave greater Intervalb Sthan 144 A Treat;fe of the than nfually; whereby the Pores will grow widerf and let out the moft fluid Particles of the Bloods Thofe Particles are commonly the Serum, which cafily difentangles it felf from the fulphurous Particles, when the Blood lofes its Motion by any Courfe whatfoever. THE Serum, palling through the Pores of the compreffed Veins, imbibes it felf in the Subftance of the Parts from whence the capillary Veins return, and penetrates into them fo as to fall into the Capacity of the Abdomen; or elfe, it infiltrates it felf in the fmall Cells of the Fat, and in the Interftices of the Mufcles which forms two Sorts of Dropfies the one called a Dropfy by Efufion, or Afcites, and the other a 'DropfJ by Infiltration; AMONG the Vifcera of the Abdomen, the Li. ver and the Spleen are moft times fwelled, efpecially the former; becaufe its Struaure confifts only of interlaced Veins, which have but a fmall Elaf. ticity; and confequently the Blood not having irt that Vifcus fo fwift a Motion as in the other Parts, it muff needs obftrut that Part, and fo comprefs the Veins, which bring the Blood back again. The Veins being compreffed by the Obftruaion and Swelling of the Liver or Spleen, the Blood flops in their Capillaries, their Ramifications become varicous, their Pores grow wider, as I have faid; the fulphurous Particles of the Blood being at reft, leave the Serum, which continually pafling through the Pores of the Veins, gathers in the Cavity of the Ab. domen, and occaflons a Dropfy. THEr Serum running ftill through the Pores of the Veins, their Coats are at laft very much relax< ed, and their Pores fe open, that the Serum flows Operations of S t R E R Y. t4Y in great quantity 5 which cannot happen without its gathering in the Abdomen, &c. And becaufe that Serum is not difflipated, for want of Heat arid Motion in the Liquids, it gathers together to fuch a Degree, that it occafions a great Tenfion in the Belly, and forms an Afcites. THE Accidents ufually attending that Difeafe are vety numerous. I could not mention, and give an Account of 'em all, without departing too much from niy Subjedt and therefore I fhall content my felfwith explaining mechanically thofe that are moft common. THE Dropfy, formed as I juft now faid, is always attended with a very great Difficulty of breathing, which encreiafes after Meals, and wherl the Patients are a-bed. The Urine is muddy, and full of Gravel, arid they void it in fmall Quantity, and with great Pain. They ate troubled with a frequent and very dry Cough. They continually call for Drink, becaufe they are very thirfty. They loath and hate all Sorts of Aliments; and fometimes they fpit Blood in the Progrefs of that Difeafe, THE Difficulty of breathing can proceed from no other Caufe but this. The Waters lying in the Belly pufh the Diaphragm towards the Breaft, and keep it from coritrafing; and the Diaphragm cannot leffen the Cavity of the Breaft, without vety much obitruding Refpiration, &c, THSt Venitricle being full of Aliments after Meals, and fituated in the Belly, 'tis plain it muft fitrtch it felf more ftillu and drive alfo the Diak phragm farther into the Breaft. Therefore the Difficulty of breathing mutft encreafe after Meals. WHEN the Patients are a-bed, the Waters, that L are 146 A Treat;fe of the are in the Belly, prcfs upwards, as alfo downward; pw ich drives the Diaphragm into the Breaft, hinders it from contradting, and confequently encreafes the Difficulty of breathing. And indeed thofe Patients are never cafy but when they are fitting. T o make a great deal of Water, the Kidnies muff.t filtrate a great deal of Urine. And becaufe the Urine is only the Serum of the Blood, and we have feen that the Blood contains but little of it, fince it lofes it by its falling into the Belly, 'tis plain the Kidnies cannot filtrate a great deal; and confequently the Patient makes but little W ater. A ND if the Tranfparcncy of Urine depends upon the great Quantity of Serum, which dilutes and divides the tartarous Salts, with which the Urine is clogged, it follows that the Urine of dropfical People, having but little Serum, can neither divide nor dilute the Salts contained in it. They unite therefore with one another; and the Urine of the Patient is muddy and full of Gravel. IF fad Impreffions and violent Irritations do frequently depend upon the Groffhnefs of the Salts, 'tis plain the tartarous Salts of the Urine of dropfical People, being united for want of Serum, and having acquired a larger Bulk, muff make hfuch fharp Impreflions, as they pals through the Urethra, that the Patients cannot but feel a fminarting Pain, when they make Water. S I N CE the Blood affords to the different Glands the Matter of Filtration, it neceffarily follows, that all the Rccrements, which are naturally watery, are wanting in the Glands, that feparate them from the Mars of Blood; for we have faid that the Blood is almoft intirely dcflitute of its Serum: Its Salts, Opeiratons of S U R G F R Y. 149 Salts, not being diluted, uniite tohetijer; Wnd aquire a larger Bulk; which irritates; the Afpera Arteria, and occafions a Cough. BuT becaufe the Blood does not aff6rd the ifLgany S rum, to be 6aft up, the Cough bof dip'licil People muff be very dry; I P the Blood cannot aIffoid td fl AtfW 'i' "R crements any S rum, becaufe it has nofle,,SHa juft now (hewed; one may eafily appreheind that the Spittle will be defltitute of Serum, that its Slts will unite and grow larger, and making an Imrprefioii upon all the Parts of the Mouth, will excite a Senfation of Thirfi; which is the Reafon why d'iopfi. cal People call continually for Drink. AcCO D ING to the fame Principles, 'tis evdent that the Salts of the Saliva being very grofs; by reafon of their Union, cannot penetrate the Aliments; and the Aliments, for want of being eafily divided, fall almoft infire into the Storamach which occafions an Indigeftion attended with a Loathing of all Sorts of Aliments. I F Blood, as well as all other inixt Bodies, owes its Fluidity to the Serum; it plainly followsi that fince the Blood of dropfical People has no Serum, it ihuft needs grow very thick. A thick Blood, running with gfeat Difficulty in its Vefrfels, flops in thofe Places, where it has lefs Motion. And becaufe the Lungs are a foft Body, which receives its whole Motion from the Blood, without communicating any to that Fluid, 'tis plain the Blood muft flop in the Lungs, and occafion a Spitting of Blood. IF the Serum is infiltrated in the fatty fmall Cells, and in the Interftices of the Mufcles, it L 2 tnufh 148 e ATreat;e of the muft needs relax their Fibers: Thofe Parts being fwelled, 0loe their Elaflicity, and confequently if they are prefled with the Finger, the Impreffion will remain in them. WHA x I have juft now faid, leads us eafily to the Knowledge of thofe Difeafes; but becaufc they requitr diffrent Operatiois, and in different Places, accordig to the particular Difference of each Difcale,. I think it is highly neceflary for a Surgeon to know the different Dropfics, which he undert kcs to cure. AqcCOiUNG to the Principles I have laid down, it appears that there are two Sorts of Dropfies, one by Effufjon, and the other by Infiltration. AGAIN, there are two Sorts of Dropfies by Effi/fion. In the firit, the Waters are diffufed in the Cavity of the Abdomen, with all the Vifcera contained in it. In the fecond, they are fhut up in a particular Membrane, called by Surgeons a Cyf7 tu or Bag. A s for what concerns the fecond Sort of Dropfy, it is a Serum diffufed, and infiltrated in the fatty fmall Cells, and in the Interftices of the Mufcles; and becaufe it is highly neceffary for a Surgeon to diftinguifh all thofe Difeafes, that he may fafely perform the Operations proper for them, I fliall mention the Signs peculiar to each Sort, agreeable to the Principles 1 have already laid down, and to daily Experience. BESIDES all the Symptoms attending a Dropfy, wilic I have mentioned, and which are the true diagnoitick Signs of it; when the Belly is much diftended and fwelled, and the Navel very much raifed, there is ground to believe that it's a Dropfy by Effuion, Operations ofSURGERY. 14 T o be the better convinced that there are Waters in the Capacity of the Belly, the following Sign ought to be added to thofe above mehtioned, The Surgeon muff put one of his Hands upon one of the Sides of the Belly, and the other on the oppofite Side. The firlt Hand leaning upon the Side of the Belly muft be at reft, whilft the other preffes and fhakes; and if the Surgeon feels a Waving of Water with the Hand that is at reft, he may be fure there is an Effufion in the Cavity of the Belly. But if he does not feel it, he may prefume there is not a fufficient Quantity of Water diffufed to perform the Operation, or that the Liquid is contained in a Bag. MR. Petit affirms that the Wave or Column of Water, determined by the Hand that preflcs and fhakes, is too extenfive, and fometinics felt but confufedly; and therefore inftead of the Concuffions of the Hand in Motion, he advifes the Ufe of Fillips, and fays that the Columns of Water, determined by them, being lefs extenfive than when the whole Hand is ufed, they are felt more diftinflty. L A s T L Y, if the Column of Water is felt but confufedly, and the Surgeon wants to know whether the Effufion is in the Cavity of the Belly, or in a Bag: Mr. Arnaud, in order to remove that Doubt, gives fome Signs, which are almoft undeniable. The Urine, fays that great Pra&itioner, in 'Dropfies by Efffion in the Capacity of the Abdomen, is defective either in 9uantity, or in Quality. It is defetive in tuantity, becaife it does not come out fo plentifuly as it ufes to do. It us defecL 3 ti-ve x 0 A Treatfe of the live in 9uality, becaufe it tomes out red, and leaves a Sediment fomewhat like Brick-duof, which precipitates to the Bottom of the Veffel. I have given above the mechanical Reafons of thofe two Fadts. The quite contrary happens in thofe propfes, that are farmed in a Bag: The Urine is clear, limpid, and as plentiful as ufually. Befides, the Patient feels in that particular 'Dropfy, a dull Pain, a Heavinfs, and as it were, a Stitch in that Part where the Bag lies: He filt them as foon as the Liquor of that Bag happened to be 7n a fuffýicient QuantitY to occafon thofe Accidents, which mu/f confequently encreafe, as the Liquor encreafes: Thofe signs are a fufficient RPrefumption to make one believe that the Dif eafe will end with a Suppuration. LASTLY, the Dropfy by Infiltration may be known by a diftended and fwelled Belly, without feeling the Column of Water from one Side of the Belly to the other: The Skin is fhining; and if it be preffed with the Finger, the Impreffion remains. But the moft certain Sign is a funk Navel, with an extraordinary Tenfion of the Belly. HERE follows the Prognolfick of the Dropfy. Since the Blood of dropfical People is very thick, and deftitute of Serum, and fince it circulates fo flow, that it may occafion Obitrudtions in many Places; it ought to be inferred from thence, that Remedies will hardly be able to reflore its former Fluidity. And if the Compreflion of the Veffls, occafioned by the Diftention of the VYfcera of the Abdomen, can only be removed by the Fluidity of the Blood, it follows that the Prognoftick of that pifeafe muft needs be very dangerous. TIE Operations of S u R GER Y. I 5 THE Blood lofing every Day Part of its Serum, and not receiving that Liquor, in proportion to the Aliments and Remedies, will at laft grow fo thick, that it will no longer be able to circulate in the Lungs, as I have already faid; and comprefling the Veficles, or falling into their Cavity through fome Laceration, it will prevent the Accefs of the Air fo that the Patient being no longer able to breath, muff of neceflity be ftifled and die. THE Blood having in time loft the greateft Part of its Serum, and leaving no Excrements in the Kidneys, no Urine will fall into the Bladder; and confequently there will be a Suppreflion of Urine. THE Blood being very thick will flop in thofe Parts, that are fartheft from the Center of Motion: It will ferment there, tear the Part, and occafion Ulcers attended with a Gangrene and Death. CHAP. X. Of the Operation of the Paracentefis, or Pun/ion of the Belly. I Have fufficiently enlarged upon the Caufes of the Dropfy, its Differences, Accidents, diagnoftick and prognoffick Signs. I proceed to the chirurgical Operations proper for thofe Difeafes. A s for what concerns the Dropfies by Effufion, whether the Waters be contained in the Cavity of the Abdomen, or in a particular Cyflus, it is ufual to void them by an Opening made upon the TuL 4 +mor 15 z 4 Treatife of the mor with an Infirument c4lled Trois-quarts, or for want of it, with a Lancet. But before the Surgeon begins that Operation, it will not be improper to put under the Lpins of the Patient a Napkin folded ipto three according to its Length, and to lay on the Scapulary, that he may have no Occafion to make him fitr, when he has drawn out the Waters. IT is ufual to make the Patient fit upon his Bed, or upon a Chair before the Operation, that all the Waters may come out more eafily, and he may breathe with lefs Difficulty. THAT Situation appears to me incopfiltent with the Dcfign of the Operator. 'Tis true that the Trunk being in a perpendicular Situation, the Waters will go downwards but thofc that are in the pelvis, and below the Puntaiop, cannot come out through the Cannula of the Trois-quarts, fince no Cormprcffiop pan be mpade in the Circumference of the PeeWti, and confequently one Half of the Waters will remain in the Belly: And as the Water comes out, the Diaphragm will defcend into the Belly; which will occafion fainting Fits. THE bcft Way of fituating the Patient is, according to the Pratice of the Hotel-dieu at Pars, to make him lie upon his Bed, and, as Mr. Petit advifcs, to lay him down upon his Side, that all the Waters may be gathered in that Place, into wvhich the Inftrument is to be thruft; and by that Means the greateft Part of the Waters will comp out. But before the Operator proceeds fo far, he muff ask the Patient, whether he felt fonme acute Pain before his Illnefs, and whether he be fenfible of any Hardncfl eithcr in the Liver, or the Spleen, Sand Operations of S RGERY. R 3 and the Mefentery: For in this Cafe the Dropfy would be a Confequence of a Scirrhus in fome of thofe Parts; and therefore the Pundion flould be made on the oppofite Side, for fear the Scirrhus fhould hinder the Waters from coming out through the Cannula. THE Surgeon muft alfo take care not to make that Operation, when the Patient is troubled with a violent Cough for befides that the Waters would not come out fo eafily, the Patient might be flifled. A FT E R a careful Obfervation of thofe Circumflances, the Surgeon muff examine the Place, where. in the Pun&ion is to be made. If we believe Authors, this Operation is to be performed in two different Places, viz. in the Navel, when it is very much protuberant, that all the Waters may come out, and four Inches above, or by the Side of the Navel, when it is level with the Belly. I fliall explain hereafter the fad Symptoms, which attend the Wounds of tendinous and aponeurotick Parts; but in order to confute the Opinion of thofe, who make the Punftion in the Navel, when it is protuberant, we need only confider the diagnoftick Signs of the Afcites, or Dropfy by Effufion, which are, as I have faid, a diftended Belly, and a protuberant Navel: So that the Protubcrancy of the Navel being infeparablp from the Dropfy by Effufion, and the Punaign in the Place, which I fliall mention by and by, leffening both the Protuberancy of the Navel, and theTenfion of the Belly; it is not only a needlefs Thing to perform the Operation in the Na, yel, but alfo very prejudicial; becaule the Pains are very great in that Part, and the Cure difficult: Bcfidqs, the Weaknefs of the Navel, occafion'd by the Operation, is attended with a Hrn~ma. THE x54 A Treatf e of the THE fecond Place, wherein the Operation ought to be performed, according to thofe Authors, is about four Inches under or by the Side of the Navel, when it is level with the Belly, to avoid, as they fay, piercing the Linea alba; becaufe it would occafion a great Pain to the Patient. I F the Operator follows this Method, he muff pierce the Mluqculus retdus in the middle, and confequently its Sheath, which is very firong, and will occafion at leaft as much Pain as the Linma a/ba. B E s I D E S, thofe aponeurotick Parts are not fo eafily reunited as the flefty ones. WHEREFORE to avoid all thofe Inconveniences, the Operator ought to meafure the Diftance between the Spine of the Ilia, and the Navel, and thruft his Infitrument in the middle of that Space: In which Cafre, the Belly is fo diftcnded, that the Cannula happens fometimes to be eight Inches diftant from the Navel. TH E Surgeon having obferved the moft proper Place to perform that Operation, fhall make ufe of a Servant to comprefs the Belly with both his Hands, in order to bring the Waters into the Place, where the Puntion is to be made, and remove the Inteftins from the Peritoneum. AFTERWAR DS the Operator muff examine his Trois-quarts, to know whether the Point be not rufty in the Cannula; that he may not be obliged to take off his Infirument, after he has introduced it into the Belly; bccaufe the Blade could not be feparated from its Cannula. IN the next place, the Operator\dips the Point of his Inftrument in Oil, holding faft the Handle in the Palm of his Hand, and the Trot'is-quarts armed with its Operatios of S U R G E R Y. 155 its Cannula between the fore and middle Fingers: And then he brings the Inflrument near the Place, wherein he is reLolvcd to make the Pundion, and thruits it fomewhat obliquely into the Belly, to direct the Column of Water towards the Vcffel into which it muff fall, and which lies upon the Ground. Or, to do better fhill, he muft hold a Vcffcl in his H-and; and when it is full, he muff put another under the Opening, whilft he empties the firft into that which lies upon trhe Ground. I have juft now laid, that the Operator muff bring his Inflrument near the Place, wherein he defigns to make the Pundion; not to imitate thofe Surgeons, who bring it all of a hddcen, and with Violence, as if they were to overcome an invincible Obflacle. Such a Method is too blunt and hafly; and one of the PerfeA ions of a Surgeon is to operate gracefully. He muff drive in the Trout-quarts, till he meets with no Refiftance; which is a certain Sign that it is got into the Cavity of the Belly. The Operator needs not be afraid of any thing: The Waters in an Afites remove the Peritonszum at a confiderable Diftance from the Intcflins. He muff only take care not to drive the Inltrumcnt upon fome Veins, which are generally very apparent and very much diftended by the Thicknefs of the Blood and the Slownefs of the Circulation; not becaufe he fears an Hemorrhagy, but becaufe fome Drops of Blood gufh out, which are unacceptable to the Stan. dcrs-by, and fome fmall Ulcers happen, which are laid to the Charge of the Surgeon. I F the Waters do not come out immediately after the thruffing of the Inftrument, though the Operator be convinced of the Exiftcence of thofe Waters by y56 1A Treatitfe oJ the by ail the Signs above-mentioned he ought not to to be unoafy upon that account, and the Patient's Friends need not be frighted. That Fault proceeds only from the Shortnefs and Smallnefs of the-Inftrumernt and therefore the Surgeon 4hall take a longer and bigger one, and make another Puntion two or three Inches under the firft. A s tlhe Waters come out, the Servant fhall prefs the Belly, and the Operator muft do the fame in fome Places, to force the Waters into the Cannula, that they may run out more eafily, and to bring nearer the epigaftric Mufdes, and all the internal Parts, which are at a great Dif1ance one from another, by reafon of the coming out of the Water; which would be attended with great Accidents, were it not for this Caution, as I fhall fay hereafter. I T happens fometimes, that after a certain Quantity of Water is drawn off, it flops all of a fudden. That Interruption proceeds only from a Body flopping the Cannula, fixch as the Epiploon, or the Intetfins. In this Cafe, the Operator introduces into the Cannula a Silver Stilet with a Button at the end, and drives away thofe Parts, that flop the Paffage of the Water. THE Patient muft neither ftir, nor cough, during the Operation; and therefore one muff take care to apply fome warm Napkins upon his Feet and Belly, and other Parts uncovered, that he may not be troubled with Cold. OUR Authors generally advife to empty the Waters at feveral Tirnes,in order to prcfcrve the Strength of the Patient, and prevent his falling into a Swoon. 'Tis true, that Symptom is very dangerous, and fome Pcrfons have not recover'd of it. But many learned Surgeons Operations of SURGER Y. 5 7 Surgeons acknowledge that this Accident proceeded only from the Patient's Difficulty of breathing, occafioned by the Ination of the epigaftric Mufcles, which being extraordinarily diftended, loft their Spring, and cqafuently could no longer counterbalance their Ant onifts. WHEREFORE to help thofe Mufcles, and reflore to 'em what the Overflowing made them lofe, we take care to prefs the Belly during the Operation, in order to bring them nearer the Vifcera, and give them again their natural Tenfion. For the fame reafon Mr. Arnaud will have the Belly to be bound tight with a Napkin; and that expert Surgeon affures us, that many Patients have been prefcrv'd by that Means. SINCE thofe mechanical Reafons, and Experiments frequently repeated, difcover to us the true Caufe of the Syncope, and teach us how it may be prevented, we need not fcruple to draw out all the Water at the firft PunCtion: This I have feen done above twenty times in the Hotel-Dieu at Paris;without any Accident arifing from it. THE Operation being over, the Surgeon takes off the Cannula, and applies upon the Opening large Comprefles dipt in warm Brandy, and over them fome Napkins folded into feveral Doubles, alfo imbib'd with Brandy: The Whole muit be kept up by the Napkin, which muft be well faftened with the Scapulary. THE Patient muft take fome Nourifhment, and fome fpirituous Liquor to ftrengthen him. The Surgeon muff come two or three Hours after to ftraiten again the Napkin, which grows loofe as the Vifcera and Mufcles refume their natural Place. WHIEN x 5 8 A Tieatfe of the W\V t the Operator has evacuated the Waters, and the Belly is altogether funk, he may touch the Liver, the Spleen, &c.* and examine whether there is any ScirrhuM. In which Cafe the Patient may be fute of a Relapfe, unlefs it be prevented by Aperitives, Diuretics, Sudorifics, and Purgatives, vwhich muff be prefcribed by an experienced Phyfician. I T being ufual for Country Surgeons to be at a great Diftance from their Houfes, and to find in defert Places fome Patients, who want to be relieved by them; I fhall give the Method of performing that Operation with a Lancet for want of the Trois. quarts. WHEN the Surgeon has done every thing abovemention'd before the Operation with the Troisquarts, he muff take a common Lancet, the Blade whereof is fatecned to the Scale with a Fillet, and thruft it into the Belly, in the Place which I have af. figned. I we confider that, which way foever the telly be opened, the Fibers of the internal and external ob. lique Mufcles are cut, becaufe they Crofs one another, the Surgeon need not be tender of them, but thruft his Lancet tranfverfly, that the tranfverfe Mufcle be only divided according to the Length and Diref&ion of its Fibers. SOME Authors, fthch as Fabricius ab Aquapenden. te, and after him Mr. 'Dionis, affirm that the Wa. ter running a long time thro' that Opening, makes the Cure of it more difficult; and therefore they will have only the Skin and the Fat to be pierced at firft; and then they get it drawn down wards or upwards to pierce the Muicles, that the Wound of the Skid Operations of SuR C GER Y. i9 Skin be not parallel with that of the Mufcles, and be fooner reunited. This Accident might very well happen in their way of operating; becaufe they cmptied the Belly only at five or fix feveral times; and becaufe they left a great deal of Water, for fear the Patient fhould fall into a Syncope, the Water had a free Paffage thro' the Wound. Befides, the Opening of the Skin not being parallel with that of the Mufcles, the S;rum meeting with an Obitacle, infilrra, ted in the Fat, and confequently prevented a fpeedy Reunion. B u r as I have {hewed by the Mechanifin of the Part, and by Experience, that the Syncope is not occafion'd by the whole Evacuation of the Water, and therefore we do not fcruple to empty it altogether; 'tis plain that when there is but little or no Warer, it cannot come out through the Wound: Which is the Reafon why we ufe no more Precautions to pierce the Skin and Mufcle with a Lancet, than with the Trois quarts. T H E Lancet being in the Belly, when the Sutrgeon depreffes it a little, and fees the Water come out, he introduces into the Belly a Silver Stilet, having a Button at the end, and that Stilet ferves as a Condutor to a filver or leaden Cannula. WHEN all the Waters are evacuated, the Operator mnuft apply the Drefling, which will not be fo myffterious as that which is mentioned in Books. He mulft ufe the Plaifter of Andreas a Cruce, opeii in the Middle, to reunite the Divifion fpeedily: He muft lay upon the Wound a fmall Linnen-Comprefs dipt in Brandy, and above it a larger one; and laffly three or four other Compreffes, and upon the whole Bellyfome Napkins folded and dipt in warm Brandy, i 6o A Treaife of the Brandy, the tight Bandage, and the Scapulary, as t have faid. T H s Method of operating is longer and more difficult than the firft $ and therefore it ought not to be ufed but in Cafe of Neceffity. BESIDES the Dropfies which are occafioned by an Effufion, and overflow all the Infide of the Abdomen, there are fome, which appear in its Circumference, and take up only certain Places in it. There Dropfies are contained between the Peritoneum and the Mufcles, or in the Interval of the two Membranes of the Peritoneum; which makes a particular Bag, called Ciflus by the Operators; and there fore thofe Difeafes go by the Name of incifed Drop, fies. THE Liquor of this Sort of Tumors, remaining a long time, is the Reafon why the Czflus thickens confiderably, and fometimes grows hard and callous. The Extent of thofe Tumors, as I have faid, is confined to certain Parts of the Circumference of the Belly, and appears outwardly with different Figures, according to the different Places, wherein that Collefion is made: But thofe Effufions generally end in a Point' and by this Sign, jointly with the others, they ought to be diftinguifh'd from the Dropfies diffufcd through the whole Capacity of the Abdomen. THE Operation of this Sort of Dropfies differs not from thofe, which I have juft now defcribed; only the Surgeon ought to know, by the Situation of the Ciflus, which is the moft proper Place to thruft the Trois-quarts; and that Situation will fometimes move him to make a larger Opening, THE Operation S R ER Y. Rf 6t THE Liquor contained in ite CyJ/is, and felt by the Touch, being always thick, the Operator muft ufe a Trois-quarts of a greater Diameter, and longer than thofe that are ufed to bring out the Waters contained in the whole Cavity of the Abdomen. I F the Surgeon, after the Operation, is fully petfuaded that there is a Cyf/is, and if the Matter has contraded fome bad Quality 5 Mr. Arnaud advifes the Operator to fyringe fobme Injetdions into it, till they come out again as clear as they were at firft -but Care ought to be taken not to leave them in it. This Pradice, far from being dangerous, is very wholefome; for it has been obferved in thofe, who died of that Difeafe, that the Parts of the Abdomen do not appear till the Bag, which forms the Cyflis, be removed. Mr. Arnaud has performed many of thofe Operations, and found very thick Matters, and of different Colours: Some were whitifh, and others being fettled grew of a Coffee-colour, and changed irnto Pus. Laftly, he faw a Woman, who had a very great Tumor in the upper Region of the Abdomen; and Part of it was undet the Cartilages of the falfe Ribs: He perceived by the Touch that there was fome Liquor, either Water, Chyle, or Bile, diffiufed into a Cyflis. The Patient confirmed him iii that Opinion; for fhe faid, that the felt a dull Pain, a Heavinefs, and, as it were, a Stitch in that Part where the Cy/tis was, and that all thofe Accidents had happenMd, 'as foon as there had been a ii-fficient Quantity of Liquor in the Cyflis to occaflon them; that they had increafed as the Liquor grew more copious, and the Tumor bigger. The Surgeon being informed of the Nature of the Difeafe by all thofe M Signs, 6z 4A Treatife of the Signs, propofed the Pun&ion; but the Patient, and her Relations, Were againft it. The other Remedies proving ineffeaual, and the Pains increafing, the Patient refolved upon the Pun&ion: Mr. Arnaud, with the Advice and in the Prefence of Dr. Lemery, of the Faculty of Paris, and Member of the Royal Academy of Sciences, drew off feven or eight Pints of a yellow Liquor, which being fettled, did not change its Colour: It was like a grofs and thick Bile. The Patient was perfefly cured. Mr. Petit performed that Operation five and twenty times for an incyfted Dropfy; and the Patient perfe&ly recovered. THERE is, among the chirurgical Operations of Mr. de la Vauguion and Mr. Verduc, a fingular Obfervation, which they afcribe to Blafius. " That " Author, fay they, tells us that he faw a confidera"ble Swelling in the lower Belly of a Woman, " which fome took to be a Mole and a Tympany. c She lived three Years in that miferable Condition: ' Her Belly was as hard as a Stone. At laft, fhe " died of Weaknefs, and when he opened the dead "Body, he found that the Skin, the Mufcles, and " the Peritoneum made but one and the fame Body, " wherein no Mufcles could be diftinguifhed. All "' thofe Parts, the Thicknefs whereof does not fre" quently exceed one Inch in their natural ftate, # were above half an Ell thick from the Navel inSto the Belly. The Out-fide of the Belly was " wholly cartilaginous, and the In-fide towards the " "Peritonxum was cancerous." I have feen a Lady, who came to Paris to confult the Surgeons about a great Tumor, with which fhe had been troubled for the fpace of two Years. That Operatios of S U R 0ER Y. 0 163 That Tumor was in the lower part of the Abdomen, from the Navel to the Pubes, It ended like a Point, and refembled a great Belly of nine Months: That Lady thought fhe was with Child the firft Year of her Indifpofition. Her Belly was as hard as a Stonel and ihe had never felt any Pain: She went away without ufing any Remedies. I think this Difeafe was like that, which is mentioned by Blakfus. HAVING fufficiently explain'd the Operations proper for Dropfies by Effufion, either in the whole Ca, vity of the Body, or in fome particular Cyflus, I fhali end this Chapter with the Operations to be performed in Dropfies by Infiltration. SURGERY affords us three different Operations for this Sort of Difeafes, viz. the potential Cautery, or the Seton, Bliftering, and Scarifications. I (hall fpeak of the two firft Methods in another Place. I Fthere was a Dropfy by Infiltration in the fecret Parts of Men or Women, they muff be fcarifi'd, In Men the Scarifications are made upon the Penis, not deeper than the Skin; and in Women, on the fides of the Lips, and pretty deep; becaufe there is a great deal of Fat in thofe Parts. I F the Dropfy by Infiltration is in the Belly, as alfo in the Thighs and Legs, Scarifications muff be made in the Legs, but never without the Advice of experienced Phyficians and Surgeons; for if fome Perfons are cured of that Difeafe, a great many die of it. WHEN the Phyfician has preferibed Scarifications, the Operator, to avoid being blamed, muff tell the Patient, and his Fiends, who expe&t to fee a great deal of Water come out, that nothing but Blood will appear, and that the Water will come afterr wards, " M;aT Si64 A Treatife of the - "H moft proper Place to make thofe Operations, according to Mr. Arnaud, is the internal and middle Part of the Leg, one upon each Side. The Surgeon performs them of the Length of the fmall Finger: He only opens the Sin and the fat Body, and does not go fo far as the Mufcles. T iH E beft Medicament, that can be put upon thofc Scarifications, is the Nuremberg-Plaifter, with many Holes in it to let out the Waters. And if thofe Scarifications grow dry afterwards, before the Difeafe be cured, and it be thought proper to make new ones, they ought not to be made on the fame Skde, but in the external Part of the Leg, and one in each Leg, as before. T H E Surgeon does not make the fecond Scarifications in the internal Part; becaufe the Waters, on that Side, being evacuated, all that Side is very much leffened. Betides, if the fecond Scarifications were made in the fame Place as the firft, or in the adjacent Part, the Humours being always difcharged through the fame Part, might be troublefome but if they are made on the other Side of the Leg, the Waters of the external Part come out, and are eafily evacuated. CHAP. XI. Of the HYDROCELE. H E Hydrocele is a Colletion of Waters in JT the Scrotum; and therefore it has been called a Dropfy of that Part. This Difeafe, as well as the SDropfy Operatmios of SURGER Y. t & f Dropfy of the Abdomen, of which it is frequently a Confequence, proceeds from the fame Caufes; and therefore I need not enlarge upon it. Ithall only obferve, that the Hydrocele may happen: after a Blow upon the Scrotum, or after a Fall, whwich comprefling the fpermatick Veffels, d&c. occafionirn that Part an Inflammation, whereby the Blood fiopping in the Veins, diftends them. THE fpermatick Veins cannot be diftended by the Blood flopped in them, without comprefling the lymphatick VefTels fo that the Lymph of thofe, fmall Tubes, being obftruded in its Courfe, will occafion the Separation of the Seram, which bchng imbibed in the Texture of the Tunicks, will relax them more and more, and make them fo thin, that their Pores being more opened will give a Patfage to the Liquor contained in them: This will produce an Hydrocele, of which there are two Sorts, one by Infiltration, and the other by Effufion. CHILDREN are more fubjeft to Hydrocdes than grown People; and even fome Children come into the World with Waters in the Scrotum. The Hydrocele by Infiltration is more common among Children than the other. THIS laft Difeafe may eafily be known; becaufe it takes up only the common Membranes of the Tefticle, which are the Scrotum and the 'Dartos; and the Water being infiltrated in the fatty finall Cells lying under the Skin of that Part, and in the Interval of the Fibers of the 'Dartos, diftends the Skin fo much, that no Wrinkle is to be feen in it; that Skin is fmooth and fhining; and if a Candle be brought near the Tumor, one may fee a Trapfparency not unlike that of a Bottle of Water. M 3 THEA x66 A Treatife of the THE Surgeon knows alfo that 'tis an Hydrocele by Infiltration, when he examins the Penis, which in that Cafe never grows leffer: On the contrary, its Membranes are fometimes fo infiltrated with the fame Liquor, that when the Difeafe is great, the Penis fwells prodigioufly; one may perceive in it the fame Tranfparence as in the Scrotum; the Glans it felf is much fwelled by the Conftridtion of a Periphimofis, which the Skin forms in it. The laft diagnioflick Sign is, that the Patient fuffers great Pains; and it appears by the Touch that 'tis Water. IF the Penis is as much diftended as the Scrotum, when the Difeafe is great, 'tis becaufe the Skin, and Fat of the Penis, tho' never fo little, are the Continuities of thofe of the Scrotum; and the latter being infiltrated by the Serum, the others muft be to too. IT is not fo with the Hydrocele by Effufion there are feveral Sorts of it, and its diagnoftick Signs are very different. Mr. Petit takes notice of three different Sorts of Hydrocele, two of which are contained in the Tunica vaginalis, and the Mufcle called Cremafter. The firft reaches from the Ring to one Inch above the Tefticle: In the fecond, wherein the Partition, which I fhall mention by-and-by, is forced, the Effufion is about the Tefticle: So that in the firft Sort of that Difeafe, the Tefticle is not confounded in the Tumor; but in the fecond, it is mixed with the Waters. I N order to give a juft Notion of thofe two Sorts of Dropfies by Effufion, let us confider the Strudure of the Parts wherein they are to be found. THE Operations of SURGERY. 167 THE Tunica vaginalis, a Membrane peculiar to the Teflicle, is compofed by the internal Membrane of the Peritonxum, which forms in that Place a Produaion, which pafling through the Openings of the epigaftrick Mufcles, furrounds the fpermatick Veffels an Inch above the Teflicle. There it has fome Adherences to the Epididymis, and they form a Kind of Partition, whereby the Tefticles are def barred from any Communication with the Belly, and then it furrounds the Tefticle. To be fully convinced of this Truth, one muift make with a Scalpel a fmallIncifion in that Tunick, above the Epididymis, and blow with a Pipe, and it will diftend it feif from the Ring to the Epididymis, without any Particle of Air pafling about the Tefticle. 0 N the contrary, if that Experiment be made upon the Tefticle, the Tunica vaginalis, formed by the fame Produfion of the Peritoneum, will be diffended, and there will be fome Air round the Tefficle, but none will pafs above it. TH Is Defcription fhews, that the Water being diffufied into the Tunica vaginalis, makes there an Hydrocele of the firft Kind, fince it is confined to the Adherences of the Epididymis; and confequently the ProdufIion of the external Membrane of the Peritonxum will make the Bag or Cy/is of the Hydrocele, in which the Tefticle will not be found. BUT if the Water is in great Quantity, or is grown acrimonious, it will force the Partition, and difflfe it felf in the Circumference of the Tefticle, whereby one may knot the fecond Sort of Hydrocele, in which the Tefticle will be confounded with the Waters in the Cyf/is. M 4 LASTLY, I 8 - A Treatife of the LASTLY, the third Sort of Hydrocele by Effuflon is, when the Waters are diffufed into the whole Scrotum. THE diagnoftick Signs of thofe Sorts of Dropfies: differ from that which is by Infiltration in feveral Rcfpes. The Tumor is not fmooth, and does not appear tranfparent: The Scrotum is not fo diftended, and there remain fome Wrinkles in it, but fewer in the third Sort of Dropfy than in the two firft; for the latter being contained in a particular Cyflis, which grows harder and thicker, as the Water has been longer in it, the Folds of the Skin do not difappear but when their Cover has acquired a confiderable Bulk. AGA I N, the Hydrocele by Effufion may be diflinguifhcd from that which is by Infiltration, becaufc in the former the Penis is not diftended; on the contrary, the more the Difeafe increafes, the more it feems to fhrink into the Belly, and the lHydrocele being at its Height, the Penis is fo flirunk, that it refembles a Navel. CHA P. XII. Of the Operation of the Hydrocele. IF the Hydrocele is a Confequencc of the Dropfy of the Abdomen, it were in vain to try any Remedy or any Operation, before the Waters of the Abdomen are evacuated: But if the Difeafe be only in the Scrotum, it may be cured, either by Medicaments, or chirurgical Operations. THE Operations of SUR GERY. I49 T1E Cure, attempted by Medicaments, does ibmetimes fucceed, efpecially when the Waters are not in great Quantity, and the Patient is young, and of a good ~Conftitution: And there is a Necefity to ufe that Method, when there is an Eryapkelas in the Scrotum. EVERY body knows that the beff Remedy for this laft Accident is a frequent Phlcbotomy; cfpe, cially if the Eryfpelaf be attended with a Fever. Topicks will relax the Skin, and confequently lef.. fen the Inflammation; and therefore emollient Fomentations are ufed with good Succefs; fuch, for inftance, as are made with the Water of Morel, Mallows, and MarifhMallows; foftening Cataplafms, &c. However thofe Remedies will not be very fuccfsful, unlefs the Scrotum be kept up with a SuJfenforium, becaufie its Weight draws it downwards, and makes it very painful. WHEN there is no Eryloelas, the Surgeon muff ufe a Fomentation made with Melilot, Camomil, &c. boiled in red Wine; and as foon as he takes it from the Fire, he muff put as much Brandy into the Decodtion, and bathe the Scrotum with the Liquor very warm, laying upon it fome Compreffcs dipt in the fame Medicament, the whole being kept up by a Sufperorium. S 0 M E ufe Deficcatives, fuch as equal Parts of Lime-water and Brandy, a little warm, and applied upon the Scrotum, in the fame Manner as the foregoing Remedy. All thofe Remedies frequently fucceed, efpecially in the Hydrocele by Infiltration: But it muft not be at its Height; for if there was a Phimofis, or a PeriphimoJfis threatening with a Gangrene, the Surgeon muft immediately 170' Tr7eafife of ibe ately make fome Scarifications upon the Penir, as I fhall fay, when I come to defcribe that Operation. THOSE Scarifications muff not go deeper than the Skin: Some ought alfo to be made upon the Scrotum. One may fometimes make two Incifions in it, one on each Side, pretty long, and not penetrating the Teguments, which are then very thick, though they feem to be very thin. This Method, pra&iced by Mr, Arnaud, is very fpeedy; but the Surgeon muff be fure that there will be no Gangrene. Afterwards he foments the Part with camphorated Brandy, and covers it with Compreffes dipt in the fame Liquor. IT ought to be obferved that all thofe different Operations muft not be performed for the Hydrocele by Infiltration, when the Scrotum is affefed with an Eryipelas: On the contrary, the Surgeon in that Cafe fhould ufe the Remedies, which I have already prefcribed, and put off the Operation till that Accident is over. IF the Hydrocele is made by an Effufion, all thofe different Remedies will avail but little, unlefs it be in the third Sort, when the Water is contained in the Scrotum: Thofe Remedies may then be tried: But to cure the two firft Sorts, there is an abfolute Neceffity to perform the Operation with a Trois-quarts, larger or leffer, according to the Size of the Patient. As for Children, one muff have a fmall one made on purpofe. IF the Difeafe be only on one Side, the firft thing the Surgeon ought to mind, before he performs the Operation, is to obfcrve where the Tefticle lies; that he may not comprcfs it, when he Operations of SURG tY. 171 he compreffes the Tumor, with a Defign to gather the Waters, in order to facilitate the Opera. tion. IN the next Place the Surgeon muft proceed to the Operation; and to fucceed in it, I muft make feveral Obfervations. Firft, the Operator ought carefully to mind thefe two things: The one confifts in piercing the Tumor with a Trois-quarts, without wounding the Tefticle or the fpermatick Veffels; for it would be attended with a Varix or Aneurifm by Effufion, as Mr. Arnaud has feen it: The fecond thing is to bring out the Waters through the Cannula. THE Operator muff therefore examine, whether he can diftinguifh the Tefticle; which he may eafily do, if the Hydrocele by Effufion is of the firft Sort, as I have plainly made it appear by the Theory of thofe Difeafes. If he cannot diftinguifh the Tefticle, he may infer from thence that it is confounded with the Waters in the Cyjf tis. The Surgeon, in fuch a Cafe, ought to have a right Notion of the Situation of thofe Parts, by virtue of his Skill in Anatomy. I T is well known that the Scrotum is divided by a flefhy Partition, and that both Tefticles adhere, on each Side, to the lower Part of that Partition. Wherefore, to avoid pricking the Tefticle, or the fpermatick Veffels, the Operator fhall comprefs the Tumor with the Thumb and foreFinger of the left Hand, that he may gather the Waters in the external Part of that Tumor; and taking with the right Hand a Trois-quarts armed with its Cannula, he fhall convey the Point of the Inftrument obliquely upwards into the Middle Part of r7, A Treatife of the of the Scrttum, and on the Side oppofite to the internal Part of the Thigh, taking care to remove always the Point of the Inftrument from the fperfttick- Veflels. STo fucceed in the fecond thing juft now mentioned, the Surgeon mufft take the Trois-quarts out of the Cannula, to let the Waters come out; and if the Water beevacuated, and none of it remains, hk muff take off theCannula, and apply upon the Srottum fome Comprefies dipt in warm Brandy, the whole being kept up with a Sufpenforium. But when a certain Quantity of Water is come out, if the Surgeon perceives there is ftill a Tumor, 'tis a certain Sign that there is a Cy/lis, which forms a double Dropfy which is the reafon why it frequently happens that no Water comes out by the firft Pundtion. In this Cafe, the Tumor ought to be pierced with the Trois-quarts in the fame Manner I have already faid, and with the lame Caution. M R. Arnaud performed that Operation upon a Man, and after he had brought out as much Water as poffible, the Tumor was only half leffcned; from whence he inferred that there was a double Hydrocele; and without lofing any Time, he pierced the fecond Tumog with the Trois-quarts, and evacuated it intirely. That Tumor was higher than the other. FIVE or fix Months after, that Man came to Mr. Arnaud, to have the fame Operation performed again and the Tumor, being pierced with the Trois-quarts, vanifhed away intirely, contrary to the Expetation of the Operator, who took it to be double. Oper at'ns of S u R R Y. I-73 T o explain this Phienomenon, one need only confider the Struture of the Tunica Vagin'a&', which I have defcribed in the foregoing Chapter; and it will plainly appear that the Acrimony:of the Water, or its Weight, had removed the Adhe-rence of that Tunick to the Epididymit, which forms the Partition above mentioned, and that it was only a very large Bag. SOME arc for a Seton; but it is only proper for Hydroceles by Infiltration, or at mofi for the third Kind by Effufion; and in this the Punation is fafer, quicker, and lefs painful. IF the Surgeon goes about that Operation, he does not convey, as the Ancients would have it, a Skain of Cotton from one Side of the Scrotum to the other; for befides that he would create a great Pain, he would certainly pierce the fpermatick Veffcls, or the Tefticles: But he ufes a large triangular Needle, through the Eye of which he pafles the Cotton; afterwards he pinches the Skin on the external Side, and in the lower Part of the Scrotum, and paffes the Needle through the Teguments, leaving in them the Cotton, which he draws from time to time; and the Water difcharges by the Orifices. I F the Surgeon ufed the Skain in the two firft Sorts of Hydrocele by Effufion, the Tefticle or the fpermatick Veffels lying open, would rub againft that extraneous Body; and then an Inflammation, and the Accidents that attend it, would quickly happen: Wherefore I always prefer the Ufe of the Trois-quarts. TH E Surgeon ought to mind in a particular Manner the Water, that comes out through'fthe Cannula 174 A Treat~e of the Cannula of the Trois-quarts. If it be clear and limpid, he muft advife the Patient to have the fame Operation frequently performed, in order to prevent the ftagnating of the Waters, which always does a great deal of Mifchief. On the contrary, if it be muddy and flinking, he muft inform the Patient the Tumor ought to be quickly opened. The fame Prognoftick ought to be made, when the Waters have been a long time in the Scrotum; and the fooner the Tumor is quite opened, the better it is. I T happens alfo fometimes, when the Waters are evacuated through the Cannula, that there comes out fome Blood, or Water very much tinged with Blood. In fuch a Cafe, the Operator, according to Mr. Petit's Advice, muff without any further Hefitation open the whole Scrotum, and look for the opened Veffel to make a Ligature in it. M os T Authors tells us that this Operation may be performed two Ways, either with the cutting Inftrument, or the potential Cautery; but they are generally more inclined to ufe the Cautery, becaufe, fay they, it makes a large Efcar, and confumes by degrees the Members, which muft be melted by the Suppuration and the Operator runs no Hazard of wounding the Tefticle, as when he ufes the Lancet. OTHERS, knowing better the Virtue of that Remedy, affirm that when a Number of Caufticks has been applied on the Tumor, and they have produced their Effet, the Efcar muff be opened with a Lancet. I am againft ufing the Cautery, for four Reafons, which appear to me plaufible. Firft, every body knows Operations of S RG ERY. I75 knows that the Cautery works very flowly; and that in the mean time, the Liquid which we fuppofe already to be corrupt, will become fo more and more. Secondly, the Effe& of the Cauftick cannot be limited, ince it operates fometimes beyond what the Surgeon defigned to confume. Thirdly, though the Cautery be applied, there is till a Neceflity of opening the Efcar; and fince an Opening ought to be made, it is better to ufe at firft the cutting Inftrument. Fourthly, in order to lay afide the potential Cautery, I affirm, we know by Experience, that being diffolved and mixed with the Waters in the Hydrocele, it makes them cauflick, and that afterwards they occafion a great Diforder. I fhall therefore give the Preference to the cutting Inftrument, but not to the Lancet; for in all thofe Tumors, wherein fome Parts are to be ufed tenderly, the Lancet is an Inftrument, whofe Point cannot be dire&ed by the Eye; and when it is thruft in, it cuts whatever it finds in its way. PERHAPS it will be faid that a good Operator perceives when he cuts fomething, and confequently that he may ufe a Lancet: But I anfwer, that he perceives too late that he has touched a Part, when it is already wounded, WHEREFORE, I am for a flrait Biflouri; and to perform the Operation well, the Surgeon muft pinch the Skin in the upper Part of the Tumor, which is commonly about the Root of the Penis. His Servant mufft do the fame; and both of them together railing the Skin and the Fat, the Operator fhall cut it with the ftrait Biflouri. As 176 A Zreat fe of the A s foon as he has made this firft Incifion, lie fees and opens the Bag, and perceives by the Moiftnefs that he is got into its Cavity. Afterwards he flides a Finger into the Opening of the Bag, and conveys upon that Finger blunt Sciffars, to open the Tumor on its Side, and in its whole Length. IT happens fometimes that after he has opened the Tumor, he fees no Tefficle; and if in this Cafe he was ignorant of the Structure of thofe Parts, as I have fhew'd above, and flhould infer from the Hardnefs of the Membranes, that they ought to be cut and confumed, he would run the Hazard of damaging the Tefticle. On the contrary, if the Teflicle be confounded with the Waters, the Tumor is hardly opened but it appears; and if the fpermatick Veffels be diftended, they ought not to be cut immediately. That Accident frequently proceeds from no other Caufe but becaufe the Waters, that are in the Bag, and in the Circumference of the Teflicle, weighing a great deal, and drawing the Tefticle downwards, the Veffels are compreffed by the Angle occafioned by the Sinuofity of the Bones of the Pubes, into which they pafs fo that the Blood not being able to afcend again, the Veins are dilated, and become varicous. IT is therefore the Part of a prudent Surgeon in this Cafe to examine carefully the State of the fpermatick Veffels, and to follow Mr. Petit's Advice, who fays, They ought not to be cut the firft Day, unlefs the Operator feels an extraordinary Hardnefs and Callofity in them; but when the Waters, or the Matters are evacuated, and the Scrotum eafed, the Blood may refume its Courfe, and the Diftertion at laft difappear. Operaions of S i GER Y. f IF the Membranes of the Bag are hard and cab IOus, the Surgeon muff cut as much of them as he can, and put upon the Remainder fome Caufficks, fuch as the Red Precipitae. or calcinated dll4m mixed together, to make an Efchar that will excite a Suppuration; and by that Means the remaining Part of the Mcmbranes will wafte aid fuppurat&. Laffly, if he can tear add take off dithe Bag, he fhall minake a Ligature in it, and cut it underneath. Mr. Arnaudtakes Notice, that there is fometimeg in the Hydrocele a fat Body, which ought to be cut and wafted by Caufticks and Suppuration. THERE is frequently an Abfcefs in the Tunica vaginalis. When the Operatot is convinced of it by the Signs of the Pus that is forming, and by the Exiflence of a Liquid, he muft open the Tumoi with the Caution above-mentioned, and make a fufficient Opening to difcover the Bag. He alfo pinches the Bag, taking care not to mix ahy Parts with it, and opens it. Afterwards he introduces into it the fore and middle-Fingers of his left-Hand; and upon thofe two Fingers he opens and cuts wvith blunt Sciffars the Tuimor and the Scrotum in, its whole Extent. IF the Telticle b6 conifounded in the Ba, he plainly fees it, when the Tumor is opened: He muff then touch it, and examine whethei he dboes not feel upon it a Fludfuation, which is a Sign of Pus, Water, or fome other Liquid. The Cafiratioti ihould then be performed, if we believe moft Aun thors;: but befote the Surgeon proceeds to fiuch an Extremity, he muitff examine the Epididymis, aicd fee whethe&it be not damaged; aird if it be found, lie mutf with a Lancct open the Abfccfs of the TcN flicl, 17)88 A 7r e a fie of t k flicle, in its whole Length, and make it fi'uppurate: And if he perceives no Callofity after the Suppuration, it's a certain Proof of the Cure of the Difcafe; but if there was a Callolity, it muft be extirpated. Mr.Arnaud performed that Operation in the fame manner I have deferibed it, and with very good Succefs. He faw another Cafe much of the fame Nature. The Tefticle was very much fwelled, and when he touched it, he perceived a Liquid immediately. He pierced the Tefticle with a fmall Troisquarts, like that which is ufed for Children, and there came out a yellow and clammy Water. The Patient was perfetly cured. T H E Drefling of thofe Difeafes being the fame as that of the Cafitration, I ihall difcourfe of it in the next Chapter. CHA P. XIII. Of the CGajration, in relation to tho/e Dh p eafis, hzv/ich reqtiire that Operation. T HE Funalon of the Tefticles confifts in fe-4 parating from the Mafs of Blood that Liquid, by which Men are propagated; and therefore a Surgeon, who ought to be prudent in all his 0 -perations, muft in a particular Manner endeavour to cure the Difeafes incident to thofe Parts, without being obliged to deftroy themn. The Exampics, which I have alledged in the fore-going Chap Operat;ons of S UR G F R Y. I 9 ter, plainly lhcw, that the Difeafes of the TefticCles may frequently be cured, without a Catfration. It is more glorious for the Surgeon, and more advantageous to the Patient, to perform the Cure with' out cutting off the Part. IN former Times, Surgeons would not have fcrupled to tie the fpermatick Veffcls, when diftendedý in opening an Hydrocele. An Abfccrs in the Teflicle, or an Effufion of fome Liquid in its Subflance, would have determined an Operator to perform the Cafiration fpeedily. But now being acquainted, by Mr. Petit's Difcoveries, with the ufual Caufes of the firft Accident, and grounded upon Mr. Arnaud's Experiments, who has many times opened the Abfceffes of the Tefticle, and ufted the Trois-quarts, to take out, with very good Succei&, the Liquid contained in its Tunicks; we cure the Patient mofi times, in both Cafes, without having Recourfe to that cruel Operation. Ho W E VE R, I don't pretend to rejeft it altogether: In fome Cafes it is not only neceffary, but even the only Remedy. What I mean is only this, that a Surgeon ought never to bring Matters to that Extremity, till he has tried whatever our Art teaches us, and whatever his Experience and Genius may fthggeft to him, in order to avoid that Operation. But if notwithftanding all his Care to preferve the diftended Veffels, after he has opened an Hydrocele, and if having tried all poflible Remedies to diflipate its Swelling, and to foften it, the Hardnefs and Tenfion continue two or three Days after the opening of the Tumor, he muff proceed to the Operation. 111 2 CASTRA' 180 A TreatIfe of tlhe CASTRATION is alfo the only Remedy, when the Surgeon having opened an Abfcefs in the Teflticle, and having made it fuppurate, and applied upon it the moft diffolving Plaifters, it remains ftill hard and callous. That Operation is alfo performed, when the Membranes of the Teftlicles are hard and callous, without having been feparated before by Waters, Pus, &c. for it appears from thence, that the fpcrmatick Veffels, and the Teiflicle, are alfo affedcd with the fame Difeafe, or that they cannot be fiparated from their Membranes, which are the Cremafter, and the Tiunica vaginalis. IT frequently happens by a Blow upon the Scrotum, or by a Fall, that the Tetflicle is inflamed, diflended, and hard, and occafions a Pain, a Fever, and many other Accidents. In fuch a Cafe, the Patient muft be blooded copioufly, and emollient Poultices applied upon the Scrotum. THAT Difeafe happens alfo in Claps ill cured, or that fall into the Scrotum. The fame Remedies w-ill cure it; and if any Hardnefs remains fill, the Surgeon endeavours to remove it with a fmall Fridion of mercurial Ointment; whick muft be done before a fmall Fire, and upon the Scrotum. Mr. Dionis fays, he has often fucceeded with the following Plaifler. Take Emplafit. Diaboton. divin. de Ran, cum Mercur. equal Parts, which yozm fall d/ifolve in Oil of Lillies a and then fpread that Plaif/er upon a Piece of Leather to lay it on the Teflicles. Mr. Arnaud adds to that Mixture Part of the Nurewbcg-Plaiflcr, which is a very good Diffolvent. THOSE differcnt Difeafrs frequently occafion. canccrous Tumiors, or. ExcrcfcCnces of a white Flefh, whicih Operations of S UR G, i R Y. I8 vwhich proceeds either from the very Body of the Tefticle, or from its Membranes. They arc difiinguifhed from Hernias; becaufe they don't happen all of a fudden, as Hernias do; becaufe they are not attended with the fame Symptoms; bccaufe they are hard, rugged, and uneven; and becaufe Hernias, on the contrary, are even and fmooth. THE Remedies juft now mentioned, have frequently fucceeded in like Cafes: They ought to be ufed a long time, and often reiterated. The Operator muft not neglect Phlebotomy, Purgatives, Diffolvcnts, and many other Remedies, which ihall be prefcrib'd by experienced Phyficians and Surgeons. IF all thofe Attempts prove ineffedeual, and the Excrefccnce increafes inftead of lefltning, the Operator muff open the Scrotum, and fee whether the Figure of the Tefticle be not altered, or faftened to its Membranes; whether the fpcrimatick Vfcflrs be not callous, and the Epididyris taken up by the felfhy Mafs. In fuch a Cafer, the Surgeon might hope for a Cure, by cutting that Excrefcence, or ufing a proper Confumptive, and end with the Suppuration. But if the Tefticle, or the fpermatick Vcflels have loft their natural Figure, and the flcfhy Mafs feems to proceed from thofe very Parts, the Tumor and tlihe Tefticle muft immediately be extirpated. LASTLY, if the Tefiicle is fo bruifecd, either by a Blow or a Fall, that a Gangrene is a neceflhry Confequence, the Surgeon mufft not put off the Caftration, which will be more or lefs fuccefsful, according to the Greatnefs of the Difeafe. For if the Veffcls cf the Tefliclc were hard, and callous cven beyond the Ring of the Obliquus externus, the Operation would N 3 not 8 A Treatife of the not be fuccefsful, and the Difeafe reaching the Bel. ly in a very fhort time, the Patient would not live long; And therefore the moft expert Surgeons are againfti the Operation in fuch a Cafe. ON the contrary, if the Patient was a Man of a good Conflitution; if the Diftention and Hardnefs of the fpermatick Vefficls did not reach beyond the Ring of the Obliquus externus; if the Putrefation or Gangrene did not reach fo far neither, and if the Caufe of the Difeafe was external; the Operation would be the only Remedy, and might be attended with a good Succefs. CHA P. MV. Of the Operation of the Cafiration. A FTER the Ufe of general Remedies, if the Difeafe allows Time enough for it, the Pafient muff lie on his Back; and -fome Servants muff hold his Arms and Legs. The Operator makes then an Inciflon in the Scrotum, which he begins near the Penis, and direaly above the fpermatick Veffels, taking care to avoid them; and therefore fome body muft draw the Tefticle a little, whilift the Surgeon cuts the Skin, to remove it from the Initrugent. IN order to make that Incifion, he flhall ufe a firait Bjflouri, and pinch the Skin in the eleded Place, jointly with a Servant; or he flhall begin the Incifion in that Part of the Scrotum, which appears the thinne; 3 being always mindful to cut at tim nothing but the Skin. AFlrER Operations of S U R G E R Y..183 AFTERWARDS the Operator fliall thruft the fore or middle Finger under the Skin into the fat Membrane, to get into the Scrotum; and he fhall enlarge the Incifion, by cutting upon his Finger, with blunt Sciflars, the Skin feparatcd from the Fat, and by that means open the whole Scrotum. IN the next place, if the fpermatick Vcdffcls make a large Bulk, and there is ground to fufpcd a Hernia, the Surgeon fhall pinch the Bag in that Part, which appears the thinneft, and open it likewife upon his Fingers in its whole Extent; which may eafily be done, if there be never fo little Serum. But if there are any Inteftins in it, and if the Difeafe lies on the right Side, Care ought to be taken not to tie the Appendix of the CUcum; which would occafion new and fad Accidents. IF the Epiploon is alfo come out, and grown hard and large, as it generally happens, the Operator, before he ties and cuts it, muft fec whether it does not contain fome Circumvolution of Inteflin. This is not a vain Obfervation. Mr. Thibaut has feen an Inftance of it; and he would have cut the Epiploon, had it not been for this Caution. THE next thing is to cut the internal Part of the Ring of the Obliquus externus, and then to feparate the fpermatick Veffels in that Place, before the Teflicle be touched, and to tic them clofe to the Rings of the Mufcles, or a little above them. IF thofe different Methods appear extraordinary, they are neverthelefs fafe, and juftified by the Pradice of Mr. Arnaud, that excellent Pra&titioncr, who affirms they fucceed better than all the others; becaufe the Ring of the Obliquus externus conmrefling the fpcrcmatick Vcfflls no longecr (fince we - N +4 havN 18 4 8 4A ideat~f of the have cut it, and we fuppofe the fpermatick Veffels to be tied a little above it ) there happens no Inflammliation in thofe Parts - an Accident, which occafions the Death of one half of the Patients, by reafon of the Symptoms with which it is attended. To make the Ligature, the Surgeon muft ufe a Fillet more or lefs thick, and fuch as I havl defcribed, fpeakiig of Sutures. He muff pafs it under the fpermatick Veifcls, puttino about it a fmall Comprefs fomewhat long and narrow: He muft tie them and the Comprefs in the fore-mentioned Place, and firaiten it very faft with a fingle Knot: Laffly, he muff make a fecond Turn, and keep it faft with a double Knot, and above it a fingle Knot. BEFORE the Surgeon proceeds farther, he muff do the fame to the Bag, I mean, feparate it with his Fingers in that Part of the Scrotum: Afterwards he muft make a Ligature in it, like the foregoing, and feparate with his Fingers both the Bag and the Tefticle from the reft pf the Scrotum, cutting with Sciliarsthofe Parts, that make too great a Refiftance. This Method is not only fafer, fince the Surgeon does not run the Hazard of occaftoning great Nemorrhage, but it prcvcnts alfo very much the Patient's Pain, becaufe the Parts are infenfibI below the Ligature. HAVING thus-f4parated the Bag and the Tefticle from the Scrotam, arid cut the hard, and carciriomatous Bodies, which made a Rcfiftance, the 0 -perator cuts the Bag an Inch below the Ligature, and the fpermatick Veffels four Inches underneath, that he may have a Hqld, in okdr to make a fecond i < Ligature, Operatons of S u R G R Y. 18 o Ligature, if the firft fhould unhappily grow loofc, or was not fufficiently firaitencd. IF this Operation was performed for a gangre ned, rotten, or crufhed Tefticle, or for fome Ex-,crefcences raifed upon it; in a Word, if there was no Hernia, Abfcefs, or Dropfy in the Tunica Vaginalis, the Surgeon, after he has opened the Scrotum, and viewed the Teflicle, muff feparate the fpermatick Veffels with his Fingers, at the Rings of the Mufcle, as I have already faid: He muft alfo cut them, and make a Ligature in the fpermatick Veffcls, and feparate the Tefticle, the Membranes, &c. I r happens fometimes that the fpermatick Veffels, and Membranes, are more bulky than before, becaufe all the Veffels are varicous. If upon fuch Occafions, the Ligature was only made about the fpermatick Veffels, as I have jufft now faid, it.would grow loofe, when the Suppuration lef'ens its great Bulk, and the Artery might emit fome Blood which would make the Cure more difficult. T o prevent that Accident, the Surgeon paffes a fiall Fillet of three or four waxed Threads into the Eye of a Needle, and pierces the fpermatick Veffels in the Middle with the Needle. Afterwards he applies a long and narrow Comprefs on each Side of the Part that is pierced: He makes a fingle Knot upon each Comprefs, becaufe it is more binding than a double one and to make an End of the Ligature, he turns the Fillet two or three times round, one or two Lines above the pierced Part, the better to flop the Blood; and' he fafit s all thofe Turnings with a double Knot, and cuts ,x86 A TreatSfe of the cuts the Thread at half a Foot diftance from the Part that is tied; which I have not obferved yet. WHEN the Surgeon performs thofe Operations, he muft always have a great many Slips of Rags, that he may wipe the Blood, and know from whence it proceeds. For inftance, in the Partition which divides the Scrotum, there is a fmall Artery, which creeps into the Dartos, and makes half a Circle: It frequently emits a great deal of Blood, which the Surgeon muff wipe, and fecure the 0 -pening of the Vefll, to make a Ligature. AF TER all thofe Operations, if the Surgeon perceives that the Angles of the Scrotum are too large and inconvenient, he cuts them, and afterwards dreffes the Wound, in the following Manner. FI R ST, he raifes the fpermatick Veffels, to put under'cm fome Pieces of fine and worn out Linnen, which Mr. Arnaud and Mr. Petit prefer to Lint, He alfo puts fome on the Sides of the fame Veflels, and upon them. Laftly, he furrounds them with Linnen-Rags, and fills the Wound with them, laying upon the whole Drefling graduated Compreffes, to reitrain the Violence of the Blood, and prevent the Hemorrhage. He faftens the whole )retling with the Spica of the Groin defcribcd above, when I fpoke of the Bubonocele and he muft add the Convolutions, as in the compleat lHrnia, taking Care to bend the Thigh on the Side of the Illnefs, before he begins that Bandage. THOSE Patients do frequently wet the whole Drcfling by voiding Urine; which occafions an Irritation, an Itching, and an Erg/pelas. To pre-.ynit that Inconvenicuce, the Surgeon puts over the Operafions of SUR GER Y. 187 the whole Drefling a Sufpenforium of waxed Cloth, pierced in its upper Part, to let through the Penis. CHAP. XV. Of the Stone in the Bladder, in relation to Lfthatomy. Shall define the Stone an extraneous, hard, and brittle Body, of different Figures, according to the.various Difpofition of the Parts of which it is compofed, and the different Places wherein it grows, and formed of Saline and grofs Particles, united together with Sulphur. S UR GEONS and Anatomifts have found Stones in moft Parts of the Body; and Mr. Petit has lately extrated above a hundred and twenty from the lower Punttum Lacrymale of a Lady. To give a right Notion of Petrification in general, I fhould take Notice of many Obfervations to be found in Books; but becaufe the Operation I am to fpeak off, concerns only thofe Stones that are formed in the Bladder, or fall into it from the Kidneys, I hflall only difcourfe of the latter, and I fhall do it as briefly as I can. THE chymical Analyfis of Stones extraacd out of the Bladder, and of the tartarous Matter to be found at the Bottom of Chamber-pots, having each of them by it feif a much greater Quantity of urinous Salt than of Sulphur; it has been inferred from bS A0.47reatf oI the from thence with great Probability, that the Oril gin of Stones was nothing elfe but a Colledion and Union of thofe tartarous Salts with a Mixture of Sulphur. I pthe Anal if of Stones extrafed out of the Bladder, and out of the tartarous Matter juft now mentioned, affords a greater Quantity of Salts than of Sulphur, and if the Colledion of thofe Principles is the Caufe of Stones, and of the tartarous Matter, it follows that thofe fame Principles are to be found in the Urine, and that their Colletion occarftons what the learned Mr. Chirac, chief Phyfician to his Royal Highnefs the Duke of Orleans, and Survey or of the King's Garden, calls a calculous Concretion. Bu T becaufe that Union can only be made, according as the Principles of the calculous Concretion happen to be near one another, and becaufe they cannot be feparated, it follows that whatever is able to depri e the Urine of the volatile Salts, which put it into Motion, and keep its Principles afunder, will very much contribute to unite the faline and urinous Salts, and the Sulphur, which I have laid down as the Principles of the calculous Concretion. This will happen, either by the Difipation of the volatile Salts, which proceeds from the Agitation of the whole Mars of Blood, from a violent Exercife, a plentiful Sweat, &cc; or becaufe the Blood is not fufflcicnti ly firnifled with thofe volatile Salts, either by reafon of the coarfe, terrefirial and iiAlph rous Nouirifhment we take, or by reafon of the Groflhefs of the Air we breathe. Wherefore thofe \who live up on a coarfe and terrefirial Food, who drink acid Wines, Operations of S u R G E R Y. I89 Wines, and inhabit watry and niarthy Places; where the Air is thick, will be more fubjet to calculous Concretions. IT appears from what has been faid, that the Urine being clogged with grofs and terreftrial Salts, and a certain Quantity of Sulphur, and thofe Principles being not kept afunder by the volatile Salts, which are wanting in the Urine or in the Blood I fay, it appears that thofe grofs and tartarous Salts will be united with the fmall Quantity of Sulphur, and form a finall Body, which we have called a Concretion. T HA T fmall hard Body, or that calculous Concretion, is fufficient to be the Center and Foundation of the largeft Stones; and whether it be formed in the Kidneys, in the Ureters, or in fome Corner of the Bladder, other fandy Concretions will flick to the former 3 and from that Colle&ion there will arife a Body more or lefs hard, according to the greater or leIfer Quantity of the Phlegm, which will leffen or encreafe the Hardnefs of that Body. THAT fmall Body, called by Lithotomifts the Kernel of the Stone, being formed at firft in very fmall Places, fuch as the Kidneys, the Ureters, or the Folds of the Bladder, it follows that its feveral Concretions muft have continually been preffed by the Parts furrounding it; and confequently more clofely united; from whence proceeds a fmall Stone, which is the Kernel of the large ones. WHEN that Kernel is large enough to dilate the fmall Cavity, wherein it has been formed, whether it be in the Kidneys, or in the other Places above mentioned, 'tis plain it will comprcfs the Blood-Veffcls that furround it, and flop the Blood; from 0go A Treatife of the from whence will arife fmall Phlogofes, which will quickly be attended with an Inflammation. That Inflammation will repell the Spirits into the Brain, and they will immediately run into the Part; and all thofe Alterations will occafion a Pain. I F the Pain is a Confequence of the Irritations, "tis plain there will be an Irritation in that Part, which contains the fmallKernel s and becaufe that Irritation occafions feveral Concuflions, the Kernel muft needs be forced out of its original Place; and if it be in the Kidneys, the repeated Concuflions will make it fall into the Ureter, the Bladder, &c. where the urinous Salts and Sulphurs of the Urine will again form finall Concretions, which being united to that Kernel by Degrees, will at laft make up. a Stone of a very large Size. A N D becaufe the Stone being then in a more fpacious Cavity, is not fo conftrained, and the calculous Concretions fuperadded to it are not preffed fo hard as they were, when the Kernel was formed, the fucceeding Petrification upon the Kernel will not be quite fo hard, which is confirmed by Experience; for when a Stone is broke, the Kernel appears to have a Covering of a different Colour and Subftance from the reft of the Stone, I have already faid, that the Hardnefs of flony Concretions depends upon a lefler or greater Quantity of Phlegm to be found in the Urine; fo that if there is a fufficicnt Quantity to keep the tartarous Salts in a kind of Diffolution, the ftony Concretions being foft and porous, their Union will only produce a porous and foft Body, that will be crufhed in Pieces with the leaft Violence. On the contrary, if the Urine wants Phlegm, the Sulphur W ill Operations of SuR G R Y. 191 will unite the Salts more clofely; and the Concretions, arifing from the Union, being fitaller and clofer, the Stone will be more compa6t and fmooth, THE Figures and Diffcrenccs of Stones may be explained by the Phlegm, by the different Difpofiton of the ftony Concretions, and their different Motion in the Bladder. Some are round, others long, oval, flat, dc. Some are fmooth, others uneven, and rugged; which is the Reafon why they have been called Mulberry-like Stones. HANING explained, as briefly as I could, the Ford mation of the Stone, and difcourfcd of the feveral Alterations, which happen to it in its Growth, I proceed now to the Signs, whereby one may know that the Stone is in the Bladder. THE diagnoftick Signs of the Stone it the Bladder are a confiderable Pain in its Neck, and that Pain increafing, when the Urine is evacuated. An Itching in the RPerineum, which reaches all along the Penis to the Extremity of the Glans; and therefore the Patients fometimes draw it fo much, that it grows extraordinary large and long. They complain of a Heavinefs in the Pubes. They can only void their Urine Drop by Drop. They have fometimes a total Suppreilion of Urine, which is over, when they lie upon their Backs. They are frequently fubjec1 to an Ereftion, a Tenefinus, and a Wearincfs. They void Fometimes a flimy Matter. Their Urine is bfometimes bloody, and fometimes clear. THo' thofe Signs fecm to prove that there is a Stone in the Bladder, yet they are often very deceitful, and may fometimes proceed from a parti-;ular Difeafe of the Bladder or Kidnics without any 1i9 A Treatife of the any Stone. But the moft certain Sign is the In' troduftion of the Catheter into the Bladder. I fhall teach the manner of performing that Operation, as well as I can (for it is very difficult to give certain and infallible Rules for founding) and I fhall fpeak of the Benefit arifing from the Catheter, when I have explained the Accidents attending the Stone in the Bladder. IT being very proper not only to know the diagnoftick Signs of a Difeafe, but alfo to explain by a fenfible Mechanifin the different Caufes of thofe Signs, I fhall fay that the Stone in the Bladder being a hard and heavy Body, it will prcfs the Parts on which it lies. That Preflion will flop the Courfe of the Blood, Lymph, and Spirits. The two former being kept in the Part, that is preffed, or in its Circumference, will diftend it, and occafion an Irritation. The latter being flopped in their Courfe will flow back into the Brain; and that Reflux being often repeated will increafe, and the Irritations, occafloned by a Colleftion of Blood and Lymph, will be the Caufe of very great Irritations attended with Pain. Such is the Explication of the Pains in the Neck of the Bladder. WHILST there is a great deal of Urine in the Bladder, the Stone will not prefs fo hard that Part to which it flicks 3 becaufe the Urine raifing it by degrees, bears up a confiderable Part of its Weight; but when the Urine is voided, the Weight of the Stone being no longer kept up by the Waters, will lie altogether upon the Bladder; from whence will arife what I have explained above. Therefore the Pain occafioned by the Stone will increafe, when the Patient ceafcs to make Water. Opratios of SU R GAR Y 193 tHE Irritations in the Neck of the Bladder cdntrafting its Sphintler, it follows that the Veins of that Part of the Urethra will be compreffed by iti and that the Blood of the fpongious Texture of the Glans and Urethra ( which is but one and the fame Continuity, as we know by InjeCtions,) will not be able to difcharge into the Veins. It muft therefore remain in the fporigy Texture of the Glans and Urethra, and diftend their Membtanies The more the Membranies are diftended, like the Strings of a Violin, the more they are fufceptibld of Vibrations. Thofe Vibrations drawing the Spirits plentifully into that Part, and the Nerves of the Urethra being, as it were, conftringed, will excite a Kind of Numnefs or Itching all along the Uret thra, which will move the Patient to rub the PenmtA in hopes of driving away the Pain. And becaufe the/Urethra paflesiunder the Arch of the Pubes, and teaches the Extremity of the Penis, I may very well fay, that the Itching will be felt in the Raphe, and all along the Penis. THOSE Who have handled the Scalpel, have ob2 ferved that the Bladder does not float in the Abdoa men with moft of the Vifcera contained in it - but they have found that it lies between the two Folds of the 'Peritonaum, and that it adheres a little to thofe Membtanes, whereof the external adtheres to the Pubes. Now if we fuppofe a Stone in the Bladder, it will always, whatever Situation it mayjr be in, draw that Part of the Bladder, which adheres to the Pubes by means of the Peritonsum,:and will make the Patient feel a Hcaviinefs in that Place. 194 A Treatife of the IN otder to void Urine plentifully, the Urine bught to meet with no Hindrance in the Urethra and if the Stone happens to be at the internal Orifice 4of the Urethra, as it generally does, it will only let out fome Drops of Urine. And becaufe all the Parts are diftended upon that Occafion, and the Urine paffing Drop by Drop occafions an Irritation by reafon of the exceffive Pain, the Patient will be obliged to quit the Urinal, and to take two or three Turns in his Chamber, in order to eafe himfelf. But becaufe the Weight of the Waters makes him very uneafy, he will take it again to void fome other Drops with the fame Difficulty. IF the Stone flops the Paffage altogether, not one Drop will come out; but the Patient lying upon his Back, the Stone will roll towards the Bottom of the Bladder; and then the Paffage of the Urethra being free, the Patient will eafily pafs his Water. SINCE the Stone compreffes the Orifice of the Bladder, the Veins that bring back the Blood, will be affeted by that Compreflion. The Blood will therefore run in greater Quantity into their Cells and the Irritations of all thofe Parts drawing a greater Quantity of Spirits into the EreStores Penis, they will contrat; which will fill more comprefs the Veins, that bring back the Blood of the Penis, and by that means will occafion an Eredion. THE hinder Part of the Penis refting upon the 'Retlum, 'tis plain the Stone, in fome Situations, will firive to go that way. Such an Effort will prefs the Veins of the Retlum, and prevent the Return of the Blood contained in them. When this happens, that Inteftin muft needs be diftended by the Quantity of the Blood, that is in its Veffels and Operati;ons of SUR GER Y. T And growing more fenfible by fuch a Diftention, the inteftinal Juice, or the Excrements, will occafiori fome Irritations in it, which will excite a continual Defire of going to Stool, attended with an Inability of doing any thing. This we call a Tenefrnzt. T H E Stone firiking every Moment againft the internal Surface of the Bladder, thofe Shocks will draw in a greater Quantity of Spirits, whereby its Fibers will be contraated. And the Glands being compreffed by it, the Humour filtrated by 'em will fall into the Bladder in greater Plenty, and come out with the Urine, like a flimy Matter. IF the Stone be uneven and rugged, it will fometimes open Blood-vefels by rolling in the Bladder; and then the Blood falling into the Bladder, and being mixed with the Urine, the Patient will make bloody Water. THE fandy Concretions adhering flill to the Stone, and the Glands not having fecreted their Liquor more than ufually, nor the Blood-vefkils afforded any Blood in the Bladder, the Urine will be, as it were, filtrated, and come out very clear. CHAP. XVI. Of the Method of found;ng, i;' Retlaion to the Difeafes of the Bladdetr. HREE effential Circumflances oblige us to probe the Patient. The firit, to let out the Urine retained in the Bladder, as a Coifequence 0 bf 196 A Treaufe of the of fome of its Difeafes. The fecond, to know whether there be any Stone; and the third, to be informed of the Condition the Bladder is in. IN order to probe in thofe three Circumftances; Surgeons make ufe of longer or fhorter, bigger or lcfler Catheters, according to the different Age of the Patients; but they are always of the fame Figure: They are bent in half their Length, and the other Part is ftrait. There are alfo Catheters like a half Bow, without any Part of them ftrait. This latter Sort of Probe was made on purpofe for the Patients, that they may probe themfelves; and the former is ufed by Surgeons, SINCE we probe, in the firft Circumitance, for a Retention of Urine, it will not be improper to enquire into the Caufes of that Retention. THE Urine cannot come out of the Bladder, either by reafon of the Relaxation of its Sphinder, or becaufe it is too much compreffed. The firft Caufe proceeds from a Palfy; and the fecond from the Diftention of the fpongy Texture of the Urethra, the Veffels whereof become varicous. WHEN a Surgeon probes a Patient for a Retention of Urine, occafioned by the Relaxation of the Urethra, he always feels fomething, which keeps the Probe from getting into the Bladder j and therefore Surgeons have faid, that there are fome Carnofities or Scars in the Urethra which prevent the coming out of the Urine. Mr. Arnaud maintains, that there are neither Carnofities, nor Scars; and Mr. Petit, who is of the fame Opinion, fays, he has opened feveral Perfons, who fliould have been affeted with thofe pretended Carnofitics, and yet thc Infide of the Urethra was very fmaooth. WuAT Operations of SURGER Y. 197 aWHAT is it then (will it be faid) that kecps the Urine from paffing; and what Obftacle does the Surgeon feel with the Probe-? TH E fpongious Body of the Urethra being difiended, as Mr. Petit fays, and its Veffels being fo too, it follows that they will take up more Room than ufually; and by reafon of thofe varicou Veffels, the Urethra will appear bigger outwardly, whilft its Cavity is very much ftraitencd by the fame Diftention of the Veffels: This is the Obitacle, which the Surgeon feels with the Probe. And becaufe the Tenfion of all thofe Veffels occafions an Irritation, the Spirits will plentifully come into them, and contra& the Sphinder; which will prevent the coming out of the Urine. ACCORDING to this Explication, the Way of curing the Suppreflion of Urine, as a Confequence of the Diftention of the fpongious Body of the Urethra, is to comprefs the Veffels, in order to force the Blood contained in them to circulate with the Mafs. This is very well cffeaed with Boiugies, Probes, and fometimes pyramidal Compreffes applied upon the Perineum, in the membranous Part of the Urethra. The Veffels being compreffed, the Urine comes out eafily and plentifully. B T if the Probe, which I have juft now de7 fcribed, be made ufe of, it will occafion fome Accidents, which will prove the more dangerous, becaufe they are not minded. Firit, the End of the ufual Probes being very long, when they are introduced into the Bladder, it will pafs above its Orifice about two or three Inches; fo that the Uriile being come as far as the Openings, that are on the Sidcs of the ufual Probes, no more will come out; 0 3 and 9 98 A Treat;fe of the and the Stream of Urine, which comes out thro' the Pipe of the Probe, flopping all of a fudden, the Surgeon will be apt to fancy that there is no more Urine left in the Bladder, though there is fome remaining ftill to the Height of two or three Inches; and if the Urine has contrated an ill Quality in the Bladder, that which remains in it, being thicker and more muddy, will irritate and corrode that Membrane, and occafion in it fmall Ulcers attended with fad Confequences. IN order to avoid that Fault, which has not been minded hitherto, Mr. Petit has invented a Probe of a very ingenious Strufture. Its Bending is very fmall, without any Shoulder, and its End, which is not one Inch ftrait, makes an end of the Bending. That Probe being introduced into the Bladder, does not reach half an Inch beyond its Neck; fo that by railing a little the Rings of the Probe, and deprefing them, one may get out all the Urine. TH I is not the only Advantage of that new Probe: It differs alfo from others, firft, becaufe the ufual Probes let in the Urine into their Pipes thro' two finall Openings, which they have on their Sides at their End. According to the Defcription I have given of the fpongious Contexture of the difendcd Body of the Urethra, it ought to be confidered that thofe Probes being introduced into the Canal of the Urethra, which is ftraitened by the Diftcntion of its fpongious Contexture, it will prcfs againft the Probe, and finding two fmall Openings upon the Sides, it will get into them. As foon as that fpongious Contcxture is in the Cavity of the Probe thro' the finall Openings, it will dilate like Operations of SURGERY. I99 like a Sponge, which after having paffed through a narrow Space, happens to be in a larger Place. And if the Surgeon at that very Moment drives the Probe to make it go into the Bladder, or if he takes it out, one may eafily apprehend that if thofe Motions are made with any Swiftnefs, the fpongious Contexture, which is engaged in the Probe, will be torn, and a great Quantity of Blood will come out, as I have often obferved. To this may be added, that after having thus opened the fpongious Texture of the Urethra, with refped to the Openings of the ufual Probe, the Irritations will be more violent; and the Spirits low ing more plentifully into that Part, the Diftention will be more confiderable: So that if the Surgeon tries a fecond time to introduce the Probe into the Bladder, he will meet with a greater Oppoiition; and if he undertakes never fo little to remove that Obftacle, he will introduce the End of thq Probe into the Opening, that was made in the fpongious Texture of the Urethra, the firft time the Patient was probed, and by that means he will open a new Way, which will afford a great deal of Blood, &c. THE new Probe does not occafion fuch Accidents; becaufe it has no Opening on the Sides, into which the fpongious Texture of the Urethra can enter, and its Extremity is fhut up with a fmall pyramidal Eminence, to be found at the end of its Stilet.. But becaufe the Stilet muft remain in the Probe, when it is introduced into the Bladder, and becaufe it prevents the making of Injctions, (but does not hinder the flimy Matter from coming out, as fome Surgeons fay y 0 4 for to0 A Treatife of the for that Matter, and even Clods of Blood come out,) Mr. Petit has contrived another Probe, which is introduced without any Opening in it; and when it is in the Bladder, there remains no Stilet, and the Waters come out plentifully. All that I can fay about that Probe, is, that I made ufe of it feveral times, and always introduced it into the Bladder with great Eafe. IN order to probe a Patient, he muft fit upon the Edge of a Chair, and lean upon the Back of it: Or clfe, he muft lie in his Bed, his Knees being fomewhat railed, and his Thighs kept afunder. Afterwards the Surgeon takes with his right-Hand a Probe dipt in Oil, that it may the better flip in. Some fay, the Operator muft hold the Probe in that Part where the Rings are, between his Thumb and fore-Finger. Others will have him to hold it with all his Fingers. Laftly, fome fay it ought to be applied upon the Tuberofity of the Thumb and the fore-Finger, in the fame manner as one holds a Condudor. All thofe Methods are arbitrary, and each of them is approved by fome Surgeons. THE Operator holding the Probe with his rightHand, fhall take with the left the Penis, and hold it up between his Thumb and his fore and middleFinger. But before he puts the Probe into the Urethra, he muft confider that there are three Things which hinder its Introdufion into the Bladder. The firft is the Opening of the Glans. The fecond is that Part where the Urethra bends to pafs under the Arch of the Pubes. The third is the Bulbe of the Urethra, or that Part where the Veramontanum, Ar the Caruncula lies, as Mr. Du'verney fays, which being difthnced by the Inflammation, as well as thd Sp hinFer Operations of SURGERY. o20 Sphintier of the Bladder, make a Refiftance to the Probe. IN order to overcome the firft Obftacle, the Surgeon muff uncover the Glans, and then he introduces the End of the Probe into the Opening of the Urethra, and holding the Peni' fomewhat diftended, he conveys the Probe (the Convexity of the Bending being towards the Pubes) to the Beginning of the Arch of the Pubes. When the Operator comes to that Part, the fecond Obftacle hinders him from going farther; but to overcome it, he makes half a Turn with the Probe, that the Cavity of its Bending may pafs under the Pubes, and be adapted to the Winding of the Urethra. In order to make that half Turn methodically, he gently conveys the Probe and the PenV towards the Groin, that is farther from him, taking Care that the End of the Probe remain in the fame Place, and be, as it were, the Center of the half Turn. All Lithotomifts are very careful to diftend the Penis, when they make that half Turn; but Mr. Petit confidering the Structure of the Part, fays that if the Penis be diffended upon fuch an Occafion, the Coats of the Urethra will be brought near one another; whereby the Probe will not have a free Paffage. Wherefore, he leaves the Penis loofe; and the Probe flips eafily under the Arch of the Pubes. We are not come yet into the Bladder: We muft remove the third Obftacle. In order to it, the Surgeon muft let down a little his right Hand, to raife the End of the probe; and if this be not fufficient, he gently feels on the Right and on the Left to find the 0 -rifice of the Bladdqr. Laftly, he pnyeys the fore and 20Z A Treatfe of the and middle Fingers of his left Hand under the Scrotum, or into the Anus, that he may introduce the End of the Probe into the Bladder. ONE would think from what has been faid, that now there is nothing fo eafy as probing; but I can affirm that though all the Precepts I have laid down, are prefcribed by the moft experienced Surgeons, and though they are right, yet as often as I probed, I found fome Differences, and did not come into the Bladder in the fame Manner; being obliged to convey my Probe fometimes to the right, or the left Side, towards the Os facrum, or the Pubes, and fometimes farther; without mentioning a thoufand other Circumftances, which may be better known by Praaice than by any Difcourfe. What I have faid, will be confirmed by the moft experienced Surgeons, whom I have feen prafice the fame Thing, efpecially by Mr. Petit, to whom I am very much indebted, and particularly for the Probe. THERE is flill another Way of introducing the Probe into the Bladder, called probing upon the Belly. In order to do it, the Operator takes the Penis in the Manner I have already faid: He lays it along the Belly, and introduces the Probe into the Urethra according to the Rules above mentioned, turning the Cavity of its Bending towards the Belly; and removing by. Degrees the Rings of the Probe from the Belly, he introduces it into the Bladder, without being obliged to make the half Turn. I have faid, there are three Advantages arifing from the Introdution of the Probe into the Bladder; that the firft confifts in facilitating the Coming Operations of SUR GER Y. 203 ing out of the Urine; the fecond, in difcovering that there is a Stone and the third, in fhewing us what Condition the Bladder is in. All that I have juft now faid about probing, concerns the firft Advantage. As for the other two, the Surgeon muff have the ufual Probes, that is, thofe with a long Beak; for thofe, that have been invented by Mr. Petit, do not get far enough into the Bladder; and cannot enable an Operator to know well what he looks for in it. W HE N therefore he has introduced the Probe into the Bladder, in order to know whether it con, tains a Stone, he makes fmall Concuffions, inclining a little the End to the Right and to the Left, without turning the Probe altogether; and accor-ý ding to the Advice of Mr. Tolet, fworn Surgeon of Paris, and the King's Operator for the Stone, he lets down a little the Rings of the Probe, that the End may be introduced a little farther into the Bladder; taking Care however not to let them down too much, left the End fhould hit the Bladder fomewhere too violently. He alfo brings fornetimes the Rings of the Probe towards the Belly, without taking the Probe out of the Sphincter, drawing a little the Rings of the Probe; and with the Help of fuch Motions he feels fome Refiftance, and fometimes hears a little Sound, which is a Sign that there is a Stone. IF notwithftanding all thofe Motions the Surgeon perceives nothing, he withdraws the Stilet; and when a little Urine is come out, he lays his Finger before the Orifice of the Probe to keep the Urinc from coming out, and to make again the fame Motions. THE 0o4 ATreatife of the THE Probe not only fhews that there is a Stone in the Bladder, but alfo enables the Operator to judge whether it be large or fmall, fmooth or uneven, hard or foft. HE knows by the Probe that the Stone is large, becaufe he always feels it at the End of the Probe, and becaufe he finds it with the leaft Motion. The contrary is a Sign of the Smallnefs of the Stone; for the Operator having much ado to find it, and feeling it at one time, and not finding it the next Inftant; he may very well conjeture that its fmall Bulk is the only Reafon why it changes its Place. THE Smoothnefs of a Stone plainly appears, when the Probe flips over it without any Refiftance. On the contrary, its Unevenefs difcovers it felf by fome Eminencies and Cavities, and by a Ruggednefs, that are felt at the End of the Probe. THE Hardnefs of a Stone is known, when the Operator feels a Hcavinefs, efpecially when it moves a little. Befides, he hears it found. On the contrary, he knows that 'tis a foft Stone, when he does not perceive fo great a Heavinefs, and when it hardly founds at all. LASTLY, the Introdufion of the Probe into the Bladder fhews what Condition it is in, that is, whether it be large or fmall, whether it be purulent, or whether there be any unequal Bridles in its Cavity. SINCE we have made it our Bufinefs to know all the Differences of the Stones of the Bladder, thofe diagnoftick Signs muft enable us to draw fome Confequences, whereby we may judge of the Succpfs or Difappointment of the Operation. I fup Operatioi of SU U'R RY. oR Stfhppofe, for Inftance, a Man of a weak Con. flitution, advanced in Years, and who has been for a long time tormented with many Difeafes arifing from a Stone in the Bladder. The Surgeon having introduced the Probe into the Bladder of fuch a Patient, and obferving by the Signs above mentioned that the Stone is very large, he ought to be very wary in his Prognofiick, and draw this Confequence, that fuppofing he was fo lucky as to extra2 the Stone, it could only be done by dilating the Wound very much, and creating a great Pain to the Patient; whereby he would quickly be brought to his Grave. In fush a Cafe, a Surgeon ought to be more tender of his Reputation, than willing to lhew, he can operate; and if the Patient and his Friends are for the Extradion of the Stone- he mufft be advifed and aflifted by prudent and learned Phyficians and Surgeons. I have feen large Stones extra&ted, both at the Hoteld-dieu, and at the Hopital de la Chariti at Paris; but the Patients, though old, being of a firong Conftitution, were cured without any Accident. WHEN the Operator finds with the Probe a Stone either fmall, or middle fiz'd; when the Patient is young, and feems to enjoy a good Health; the Prognoftick, in all Appearances muft needs be very good. I fay, in all Appearance; for I have fcen very young Patients, of a good Conflitution, who bore the Operation with great Courage; and yet they quickly died, though the Operation was well performed. On the contrary, I have feen lean and languifhing Patients, who re-. covered fo fall, that all their Friends were amazed at it. PaRo to6 A 7reatfe of the PROB ING may alfo afford good or bad Confe-" quences about the State of the Bladder; for if it be very large, and contains a Stone of a middle Size, and if the Patient whether young, or old, be of a good Conftitution, the Prognoftick muft needs be very good; tho' ftill more fo indeed, if the Patient be young. But, on the contrary, if it appears by the Probe that the Bladder is finall, and the Stone very large, whether the Patient be young or old, the Prognoftick is very doubtful, and will be very bad in the laft Cafe. IF the Bladder be not large, and contains but a fmall Stone, and if the Patient appears to be a Man of a good Conftitution; there is Ground to hope for a good Succefs, efpecially if the Patient be young. THERE are alfo fmall Bladders, which contain only a Stone of a middle Size, but they are, as it were, grown horny. When fuch things happen to be in a Man, old or young, lean and languifhirrg, it is a Sign of Death: And if the Patient recovers on account of his Youth, he will be troubled with an incurable Fiftula, as long as his Blood continues to be as bad, as it is generally in fuch Cafes. C HAXP. Operations of S R G t RY. 207 CHA P. XVII. How the Patients ought to be prepared for the Operation of Lithotomy. W HEN the Surgeon knows, by the Signs above mentioned, that there is a Stone in the Bladder, and after he has deduced from it the diagnoftick and prognoftick Signs, he muff, if he refolves upon the Operation, prepare the Patient fome time before by feveral Remedies, as I am going to fhew. THE Defign of Phyficians and Surgeons, in fuch Preparations, is to make the Blood fluid, that no Diforder may happen in the feveral Parts of the human Body, efpecially in thofe, wherein fome Divifions are to be made. It plainly appears from this Indication, that fome Patients require longer Preparations, and a more particular Care than others. THOSE Patients, who feem to have a good Conftitution, and to whom fome Remedies have been lately prefcribed, fuch as Phlebotomy, Purges, &c. do not want a long Preparation. On the contrary, thofe that are wafted through Sicknefs, and have but little Strength; thofe who have been in Want, or have had a bad Food, and are confequently weakened by the Pains and Infirmi. ties arifing from the Stone I fay, all thofe Patients 2d8 A Treat;re of t e ents have an acrimonious and falt Blood, which cannot be altered in a little time. LAST LY, thofe Patients, who, though full of Humours, have ufed no Remedies in their Difeafes, and thofe who have ufed them for a long time, hoping by that Means to avoid the Operation, I fhy, all thofe Patients ought to be more particularly minded in the Preparation; the former, to evacuate the great Plenty of bad Ferments, and fuperfluous Humours; and the latter, to reffore the Strength which they have loft by the Aaion of.a great Number of Remedies, that have, if I may fay fo, overthrown the natural Order of the Liquids, and the regular Funaions of the Organs. THERE is no Place, where People troubled )ith the Stone are better tended than at the HoT 1-dieu, and the Hopital de la Charite at Paris. 'THE Operators in thofe two Places are doubtlefs fome of the moft experienced, and have a particular Dexterity in that Operation. The Aliments, prefcribed by Phyficians and Surgeons, are carefully diftributed; which is of great Ufe to cure the Patients. LASTLY, the Number of the Patients, that are cut every Year in thofe Hofpitals, is fo great, and the Succefs fo happy, that I thould wrong the learned Surgeons, who exercife their Profeffion in. thofe two Places, if I did not follow them'iin that Operation. As foon as the Patients come to the Hoteldieu in order to be cut, "tis ufual for the Space of a Week to let them refi, to refrefh them, and to fweeten their Blood with fome Emullfions, Rice anc Operations of S UR GE.R Y. 209 and Chicken-Broth, or to ftrengthen them with good Food, according to their Wants. SOME Patients, efpecially Children, happen lometimes to be troubled with Worms, or are fufpccted to be fo. The Remedy prefcribed to them on that Occaflon is Mercur. Ddulc. which they take every Night for four Days; and on the fifth Day in the Morning they are-purged. Thofe Remedies are repeated as often as 'tis thought neceffary. But becaufe the Mercury heats fometimes the Mouth, and may excite fmall Ulcers and a Salivation, I think that inftead of the Mercur. Dulc. one might prefcribe the clEthiop. Mineral. which has the fame Effe&, and is not attended with the fame Accidents. A moiftening, cooling, and foftening NourifI7 ment is given for a fufficient time to thofe, wh,. feem to be of a bad Conftitution, and are wafted through the Violence of the Difeafe, and the bad Food they*have ufed at Home. The fame Care is taken of thofe, that are lean, weak and languifhing, by having taken a great many Remedies, efpecially with a Defign to prevent the Operation, and which were frequently given them by Quacks and ignorant People. T Hi only Remedy, given to thofe two Sorts of Patients, is a very gentle Purge' two Days before the Operation; and the next Day, they are blooded according to their Strength and Age. Thofe who feem to be of a pretty good Conflitution, are blooded after a Week's Reft. Phlebotomy is repeated the very next Day; and they are purged the two following Days, the firft Day gently, and the fccond Day more ftrongly. P LASTL Y, 7o rA %eaýife of the LASTLY, on the Eve of the Operation all thofe Patients take a Clyfier 1 and the next Day in the Morning, three, or four Hours before theO peration, grown Men eat two new-laid Eggs, and Children but one, with a large Glafs of Wine, or a finall Toaft with Wine and Sugar. C H R P0 XVIII. Of the Operation of Llthotomy, or the ExtraHbon of the Stone. O F all the Seafons of the Year, that which feems to be the moft proper for Lithotomy, is the Spring, about the Beginning of May. T H E Surgeon pitches uponrthat Seafon, becaufe the Air is pure and clear, and the Heat moderate; for great Heats are contrary to that Operation: Which is the Reafon why the Patients are alfo cut about the Autumn, viz. in September, till the Middle of Otlober. Ii the Heat be very great on the Day pitched upon for the Operation; if it was alfo very hot Weather the foregoing Days; and if it thundered on the appointed Day; the Operation muff be put off, till the Weather be more calm; for the Air being hot, and likely to caufe Thunder again the following Night, fuch Accidents might happen as would occafion the Death of the fick Perfons. Some grow only weak, and have a fmall Sweat; but, others having been frighted, their Pulf~ is irregular, becaulfa Operaiouns of SUR G ER Y. -11 becaufe they had no Reft in the Night, anid becaufd Their Blood is in Motion by reafon of their Fright. I was once at the HOpital de la Chariti at Paris, when about thirty Patients were cutr Two or three Days after, the Weather grew very hot: It thundered with great Violence a whole Day and Night; and that Storm occafioned the Death of ten or twelve Patients. The next Day after thofe Oi perations, many Perfons were cut at the Nteil-dies, and becaufe they were affe&ted by the Storm much in the fame Manner, fome of theit died alfo; b-ut,tho' the Patients were in greater Number, yet the Lofs was not fo confiderable. AN exceflive Cold iS alfo very pernicious to thofe' that are cut; for it occaftons a Rheun, and confequently violent Motions to co'Uglh; which prevents the Re-union - of the divided Parts. From whence it appears that the Room ought tof be kept warm, and that proper Remnedies for a Rheum ought to be given to the Patient. But ntwithflanding thofe Precautions, the Fever dss fre4uently happen with a Defluxion of the Breaft5 and fometimnes the Patient dies. LASTLY, the Room, where the Patient isI and thofe that tend him, muff be elkan: The Linnen made ufe of at every Drefling ought to be new wafhed. ALL thofe Things being thus prepared, and die liatural Parts of the Perfonl, that is to be cut, being ihaved, the Surgeon muft call for a fMil to put his Inftruments in; and their fIimm'nftoih' u6tight to be fuitable to the Size of the Patient, The Initruments proper for Lithotoimy a4rd a,,flid Probe, with a large Bending, which begirs hih a P 2 blunt S: A Treatife of toe blunt Shoulder, and it ought to have a Groove ir its Convexity. That Probe ihould be made of Steel, that it may be faffer, and make a greater Refif tance to the Impreflion of the Bif/ouri. Its Rings ought not to be like a Circle, as thofe of Probes, but -ike an S on each Side, or like two fmall Wings that reprefent a Heart that a more extendld Surface may give the Surgeon a better Hold. Afterwards the Operator places upon the Difh the Conduftor, Forceps, Scoop and Hooks. I fhall ipeak of thofe Inftruments, when I come to give a general Defcription of them. In the next Place, the Surgeon takes a Fillet, about one Foot or one Foot and a half long, and fplits it at one of the Ends, about the Length of fix or feven Inches. He rolls the Fillet about an opened Bflouri, called by tome Lithotomus, to faftcn its Blade upon the Scales, and when the two Heads of the Fillet are flopped with two Knots, he puts the Biflouri in the Middle of the Difh, upon a fquare Comprefs, which will be of ufe, as I fhall fay hereafter. AFTERWARDS a proper Place muft be pitched upon, for a convenient Situation of the Patient. At the Hotel-dieu, where that Operation is very common, there is a Bed made on Purpofe, very high, and obliquely fituated. But becaufe fuch a Convenience is not to be had in private Houfes, they ufe a fquare Table, upon which they lay down a Chair, placing the upper Part of its Back at four J]iches dilance from the Edge of the Table i and there they make "it faft with Ropes tied about the Feet of the Table. They lay upon the Back of that Chair many Blankets doubled fix or eight times, aad over them fome Pillows; laftly, they cover the Swhole Operations of SU GER Y. 2 -whole with.a large Sheet doubled four 6ri-x tinmes. The Table ought to be fituated in fuch a Manner, that the Light.may fall a little fideways upon' that Place, where the Operation is to be performed" T H s Apparel being ready, the Patient is laid upon that Table, where his Buttocks are foniewhat raifed, and his Head and Body half inclined backwards. But to keep the Patient in a fteady Sittiation, he muff be bound with two filk or thread Ligatures, each four Inches broad, and two Elis and a Half Long, fowed together in the Middle. The Operator applies the fowed Part of thofc--Ligatures to the lower Part of the Neck behind the Head, and brings the two Heads of every Side: over the Shoulders. Afterwards, he takes the two Heads of one Side, and a Servant thofe of the oppolite Side; and then both of them fand before the Patient, and make him fct his Feet againftI'cm. In the next Place, the Surgeon and the Servant take the Heads of the Ligatures which are upo-i the Shoulders; and each of them on his Side conveys one forwards over the Clavicula, and the other backwards over the Omoplate, to crofs them boxt!h under the Arm-pit, turning them three ortfour times, as if they were to be twifted together. Af-' terwards the Patient bends his Thigh; ianid one Head of there Ligatures is conveyed to its internal Part, and the other to the external, that they may be croffed with two Turnings at the hinder and middle Part of the Thigh. Which bcing donc, the Heels of the Patient arc brought near his Buttocks, and one Head is conveyed to the internal and lowcr Part of the Leg, and the other to the external: They are croffed upon the Inftep, and conveyed inP 3 tcrnaiiy 2X4 A. Treatife of the ternally andI externally under the Sole of the Foot; where they pafs one over the other. Afterwards, the Hand of the Patient is brought near the external Mal/eoues; and he lays his four Fingers under the Sole of the Foot, and the Thumb on the upper Part: And then the Hand in that Situation is bound with the two Heads of the Ligature; the Wrift being faftened with the lower Part of the Leg, and the Fingers with the Foot. W H N the Patient is thus bound, the Surgeon puts him inr the moft convenient Manner, to perform the Operation more eafily and fafely. Afterwards, he places the Servants, who are to help him. The firit is upon the Table, behind the Chair: He lays the four Fingers of each Hand upon the Claviculas, and the Thumbs upon the Shoulders oof the Patient, and fo keeps him always down upon that Bed. Two other Servants ftand on both Sides of the Patient: They lay one Hand up3on his Knee, and the other upon his Foot, taking Care to keep them afunder, and to fupport the Patient. A fourth Servant ftanding upon a Chair near the Table, on the right Hand of the Patient, raifes the Scrotum, and bends the Skin, as I fhall fay by and by. A fifth Servant, on the right "Hand of the Surgeon, holds the Inflruments, to give them one after another, and to take them from the Operator, in prder to put them again upon the Difh. THE Surgeon, flanding between the Legs of the Patient, takes the grooved Probe, dipping it into Oil, and introduces it into the Bladder, in the Manner above mentioned; and when he feels the Stone, he bids the fourth Servant, who flands on Operations f SUvR GER Y. 2 I on the right Hand of the Patient, to raife the Scrotum; becaufe I fuppofe, the Incifion is to be made on the left Side of the Perinmum; for if it was to be made on the right Side, that Servant fhould be on the left Hand. The Servant takes the Scrotum very nicely with one Hand, and then brings the other to hold it up, whilft the Operator, who holds the grooved Probe with his left Hand, brings its convex Part againft the oppofite Surface of the Urethra under the Arch of the Pubes, in fuch a Manner that it may rife at one Inch's diftance from the Raphe. Then the Servant, who is appointed to hold the Scrotum, lays the Fingers of the Hand, which held it, on the Side of the Raphe, and of the RiCe of the Probe. But the Thumbs ought to be laid in fuch a Manner, that they may not comprefs the Scrotum; for that Compreflion does frequently occafion an Inflammation, a confiderable Tenfion, and a great Abfcefs, which generally deprive the Patients of their Lives, as I have obfcrved, though the Operation had been performed by very able Lithotomifts. The Thumbs muft alfo be laid in fuch a Manner, that they may not confirain the Operator in moving the Probe. In order to prevent all thofe Inconveniencies, Mr. Thibaut places them on the Out-fide, bringing the fore-Fingers on the Sides of the Staff, and drawing the Rafph a little towards the right Side. THE Surgeon, holding the Probe faft towards the Skin of the Perinxum, takes the Biftouri from the Servant, who holds it in the Middle, the Blade towards the In-fide of his Hand, and the Wrift fomewhat bent. The Operator takes it in the fame manner as if it was a Writing-Pen, and puts it into his P 4 Mouth, I 6 A 'Treat fe of the Mouth, that he may feel with his fore-Finger the Place, that correfponds with the Convexity of the Probe, and look in that Place for the Groove of the Probe, juft as a Surgeon looks for a deep Vein, in order to let blood. When the Operator feels the Groove of the Probe, and perceives that Part of the Skin, which correfponds with it, he takes the Biflozri, that is in his Mouth, and conveys the Point to the Place which he has obfervcd, thruffing it gently till it be got into the Groove of the Probe; and then he defcends towards the Anus, inclining the Initrument to make it cut with the Edge, that he may fave the Point, which mufft cut entirely what the firft Stroke of the Bi/ouri did not cut, afcending towards the upper Part of the Incifion, and defcending again towards the lower. But becaufe, according to this Way of making the Incilion, the Surgeon cuts more of the Teguments than of the Urethra, there is another Dilatation, which confifts in conveying a little the Point of the Biflouri, and the Probe towards the Necck of the Bladder, holding the WVift downwards, and taking care that the Point of the Biflouri does not leave the Groove of the Probe: For when the Biltouri cuts the Teguments and the Urethra alike, it does fometimcs pierce the Ret/um. Afterwards the Operator afcends to the upper Part of the Incifion; and when he is come to it, he holds the Bifouri down on the right-Side of the Patient, and bids the Servant, who holds the Scrotum, keep the Biflouri in that Situation. S uN c i is Mr. Thibau-t's Method of making the I cifion: Hc fays, it ought to be made under the.Arch of the RPubes; that its lower Anglc muff be at Operations of SU R GE RY. 217 at two Inches Diftance from the Edge of the Anus; and that the Incifion fhould be of a different Length, according to the Difference of the Patients and Stones. For inflance, if it be a Child, as far as nine or ten Years of Age, and if the Stone be fmall, or of a middling Size, the Incifion muft be an Inch long. From ten Years to five and twenty, if the Stone be large enough, the Incifion ought to be two Inches long. Laftly, for the largeft Stones, and for the oldeft People, the Incifion muft be three Inches long. Mr. Marechal, Counfellor, and chief Surgeon to the King, conveys immediately the Point of the Biftouri almoft to the fame Place, where the Incifion is to end; and from thence he afcends towards the Penis, and defcends in the fame manner as I have fad. It may be faid in his Praife, that he performs that Operation with fuch a Dexterity and Quicknefs, that I have feen him cut eight Patients in half an Hour and fome Minutes. THE Incifion being made, of a Length fuitable to the Patient and the Bigncfs of the Stone, and the Biflouri being flopped towards the upper Angle of the Incifion, and held by a Servant with the Point in the Groove of the Probe; the Servant intrufted with the Infiruments, prefents to the Surgeon the Condultor dipt in Oil: (I muff obferve by-the-by, that all the Inflruments which are to be introduced into the Bladder, ought to be firit dipt in Oil:) the Surgeon takes it, concealing the Branches in the Palm of his Hand; and laying his foreFinger upon the Eminence, that is all along that Inftrument. He conveys it, with the Help of the Biflouri, into the Groove of the Probe 3 and then bids the 218 A Treatife of the the Servant withdraw the Biflouri; and the Operator removing a little the Rings of the Probe from the Belly of the Patient, conveys that Inftrument into the Bladder with the Probe, taking care not to thruft it too far; for if it be a narrow Bladder, it will pierce the Bottom of it, and occafion Death. This Accident has frequently happened; and Mr. Fauvel, a Scholar of Mr. Mery, told me he had opened many Bodies of Patients, who died foon after the Operation; and that he found the Bladder pierced at the Bottom in feveral of them. The Operator knows that the Condu&or or Gorgeret is in the Bladder; becaufe he plainly perceives he is in a large Cavity 5 but the moft certain Sign is, that when he gets into it, he fees the Urine come out thro' the Wound, tainted with Blood. He muft then take out the Probe. THE Lithotomifts at the flopital de la Charite do generally turn the Eminence of the Condudtor (after it has been introduced into the Bladder) towards the lower Part of the Wound; and holding it with the left Hand, they convey the Fore-finger of the right Hand into the Bladder, driving it very far: Thus they make the Dilatation of the Wound. I ihall by and by mention the Method ufed by the Lithotomifts at the Hotel-dieu to make that Dilatation. IF the Surgeon makes the Dilatation of the Wound, as I have juft now faid, he takes hold of the Condutor with his left Hand, and takes from the Servant entrufted with. the Inftrunents the female Condutor, which he takes in the fame Manner as the f6rmer, and introduces it into the Bladder, conveying it above the Eminence of the firft or male Conduftor. THOSE Operations of S uR G E R Y. li 9 T HO E Inftrumfents being in the. Bladder, the Surgeon holds the Extremities, which are between the fore and middle-Fingers of his left-Hand, having thofe Infiruments in the Infide of the Fingers, the Hand being fituated in fuch a manner, that the Fingers be above the Wrift, and their external Part be next to the Wound. In that Situation, the Servant entrufted with the Infiruments, prefents to the Operator a ftrait or crooked Forceps, as the Surgeon thinks fit; and the latter fliding it between the fore and middle-Fingers, and the Condnpors, drives it, by the Help of them, into the Bladder. Mr. Marechal does not make ufe of the Condudtors, but inftead of them he introduces the Gorgeret into the Bladder, and conveys the Forceps above the infirument. WHEN the Forceps are in the Bladder, the Surgeon takes them with his left-Hand to withdraw the male and female Condudors, beginning with the latter. Afterwards he takes the Rings of the Forceps with both Hands, and thrufts them towards the Bottom of the Bladder; and then he opens the Forceps fide-ways. Such is Mr. Thibaut's Method of dilating the Wound, which he prefers to the former abocv-mentioned, for feveral Reafons too long to be here explained. That Dilatation being made, the Operator muft fearch for the Stone, and when he feels it, he charges and extrads it. I r, the Forceps being introduced into the Bladder, the Rings are too far remote, the Surgeon muft introduce into the Bladder under them the Button of the Scoop, and feel the Stone, to know whether its Bignefs is the Caufe of that Widenefs or whether it be that the Stone is too near the Rivet 2o A Treatife of the vet of the Forceps; pr whether being of an oval Figure, the Forceps charge it by its greateft Diameter. I F the Dilatation of the Rings of the Forceps is occafioned by the Bignefs of the Stone, the only Remedy is to extra& the extraneous Body, by taking the Rings with the right-Hand; and conveying the left-Hand near the Wound, the Surgeon makes feveral Motions on all Sides, d&c. If the Dilatation of the Rings of the Forceps proceeds from the too great Nearnefs of the Stone to the Rivet, the Surgeon muft repel it a little with the Button. But the beft way to prevent that Accident, is to get fuch Forceps made, as are only uneven about one half of their Length, and that the neareft Place to the Rivet be fmooth, that the Stone may flide upon it. I am indebted to Mr. Petit for this Obfervation. LASTLY, if the Dilatation of the Rings proceed from this Caufe, viz. That the Stone being of an oval Figure, is pinched by its two Ends, the Surgeon muft endeavour to turn it; and then he takes it out, as I have fhewed above. WHEN the Operator has extra&ed the Stone out of the Bladder, if he perceives in it fmooth Surfaces, which feem to proceed only from the rubbing of another Stone, he muft introduce the Button into the Bladder, and convey over its Ridge a Pair of Forceps much fmaller than the former; which he muff do as often as he thinks there are Stones, without making the Patient fuffir two or three Days after the fame Operation, taking care however that the Patient be ftrong enough to bear the Operation. BUT if the Surgeon fhould extract a foft Stone, and fome Fragments flould remain in the Bladder, he muff not introduce the Forceps or the Extractor. Operat;ons of SURGERY. 1i tor. On the contrary, he muff put a Tent in the Wound, as I am going to fay; and that Graveljwill come out afterwards with the Urine. THE Operator extracts fometimes with a Stone fome Excrefcences, which are only formed by an Ulcer or tearing of the Bladder. This Accident is frequently attended with Death 5 or the Patient remains fiftulous. LASTL Y, when the Surgeon has extra&ed the Stones out of the Bladder, he muft lay upon the Wound the fquare Comprefs, on which the Biflouri was placed, and then untie the Patient, and carry him to his Bed. THE Method of operating, which I have defcribed, is called the great Drefling, or Cutting upon the Staff. I have faid nothing of the high Dreffing, which confifts in making an Incifion above the Pubes, in opening the Bladder at the Bottom, and extra&ing the Stone that Way. If I have paffed over in filence that Method, 'tis becaufe I never faw it praticed, and becaufe it is now wholly laid afide. Yet if one refle&s upon the Experiments, which I have mentioned to prove that the Wounds of the Bladder are only mortal in thofe Parts wherein the Urine flays for fome time, it may be inferred, that a Wound made with a cutting Inftrument, at the Bottom of the Bladder, might be as eafily cured as at the Neck. Befides, we have fome Inflances of it in the Antients: Wherefore I hope that Operation will be revived in time, and that the learned Surgeons of Paris, who make it their bufinefs to find out the plaineft, the fafeft, and the fhortefl Ways of operating, will give us hereafter fome Inftances of it. I fay the fame about the Incilions..... **.-**.* 2.4 Treatife of the Incifions of certain Parts of the Abdomen, to which they arc now, avcfe.; but I have feen them practiced by my Father with very good Succeis. THE Situation of the Stone obliges us fometimes to make ufe of a third Method of Operating. For inftance, when it is very near the Perineum, and in the Neck of the Bladder, one muft perform the Operation of Lithotomy with the Little Drefnpg, which is Cutting upon the Gripe It is fo called, becanfe it does not require fo many Preparations as the Great Dreffrig. IN. the firft place, the Patient is brought to the Edge of his Bed, with his Heels clofe t6 his Buttocks, and the Knees afunder. Afterwards, the Surgeon dips the fore and middle-Fingers of his left-Hand in Oil, and introduces them into the Anus, as far as he can, to put them beyond the Stone, in order to bring it nearer, and to raife it behind. Which being done, the Surgeon bids a Servant raife the Scratum; and holding the Bifouri with his rightHand, he makes an Incifion upon the Tumor, and takes out the Stone, by preffing the Extrator behind its upper Part. Novemb. 17. 7 3. I faw that Operation performed at the Hotel-Dieu, upon a Man, who fcem'd to be between five and thirty and forty Years of Age. The Stone lay in the Neck of the Bladder. Mr. Thibaut raifed the Scrotum with his left-Hand, and with the Thumb and fore-Finger, he preflEd the Stone towards its lower Part to fecure it j becaufe it was immediately under the Scrotum. Afterwards, he made an Incifion with the-Bifouri or SLithotemus, upon the whole Extent of the Stone, and' Opefations of SuRGR Y. 2 23 and extrafted it with the Scoop; the Patient being in his Bed. BEFORE I make an end of what concerns the Operation of Lithotomy, I muft fay Iomething about the Method of extrading the Stone out of the Bladders of Women. TtrEY are lefs fubjea to the Difeafesof the Bladder than Men becaufe the Canal, which conveys their Urine out of the Bladder, is much fhorter, Otraiter, and larger than that of Men. And therefore there is not fo much Difficulty in probing Women: It is enough to make them keep their Thighs afunder, whether they lie or fit upon the Edge,of a Chair, to keep the Lips afunder, to raife the Clitoris, and to introduce a ftrait Probe, fomewhat crooked at the end and it will get into the Bladder without any Oppofition. WHEN the Surgeon knows by the Probe; that there is a Stone in the Bladder of a Woman, he places her, as well as Men, upon the Bed above defcribed. She muft be tied in the fame Manner; and fome Servants muft fland by her, performing much the fame Office, as when a Man is cut. EVERY thing being ready, the Servant who rais'd the Scrotum of a Man, keeps the Lips afunder with his two fore-Fingers and the Surgeon railing a littie the Clitoris, as I have already faid, perceives the Urethra, into which he introduces at firft the MaleCondudor; and as foon as it is in the Cavity of the Bladder, ht fearches and fecures the Stone. When he has found it, he conveys the Female-ConduCor into the Bladder. Thofe two Inftruments being in the Bladder, oight to be kept afunder, to dilate the Urethra in order to make room' for the Forceps. After 14.4 Treati~e of the Afterwards, the Operator puts the Condufors be. tween his fore and middle-Fingers, as I have faid, fpeaking of the Operation performed upon Men, and thruits the Forceps into the Bladder: And then he takes out the Condutors, and charges and extrafts the Stone, as I have faid, in relation to Men. He lays immediately a Comprefs upon the Opening of the Canal of the Urethra, to keep the Air from getting into the Bladder: He unties the Woman, and dreffes her, as I fhall fay hereafter. THI s Defcription is nothing but what I have feen practiced, at three feveral times, by Mr. Thi: baut one of the moft dexterous and experienc'd Lithotomifts in our Days. THE Operation being over, and the Patient being in Bed, what remains is only to give an Account of the Drefling. THE Surgeon bids the Patient raife her Knees a little, and keep her Thighs afunder; and then he takes off the Clods of Blood to be found in the Wound and its Circumference. Afterwards, he a&s differently, according to the Stones that have been extraaed for if the Stone is foft, if it has been bruifed, or if there is any ground to believe that fome Fragments remain in the Bladder, the Surgeon muff keep the Incifion open with the help of a Tent or a filver Cannula, to facilitate the coming out of extraneous Bodies, fuch as the Fragments or other Matters. But if he ufes a filver Cannula, it being hard, and about five or fix Inches long, it may be very troublefome to the Patient, and frequently occafion Diforders, which might perplex the Surgeon. In order to avoid the Inconveniencies of the Cannula, without lofing the Operation o SfURGERY. 2 the Benefit of it, the Operator puts in a pliant Cannula, covered, in its whole Length, with a Fillet, and paffies two fmall Heads of it thro' the Rings: Afterwards he makes faft the Cannula, with a fmall Fillet or Comprefs, and fplit in the Middle for the Paffage of the Inftrument. The Surgeon, who has invented that Cannula, is a great Operator, and a Man of a great Genius: 'Tis Mr. Tolet, the King's Lithotomift. IN order to introduce the pliant Cannula into the Wound, it ought to be armed with its Stilet, and the Surgeon muff introduce his fore-Finger or the Button into the Bladder, and convey the Cannulk with their Help. Afterwards, the Patient is differently dreffed, according to the feveral Methods of the Operators. Mr. Guerin, heretofore Mafter of the Hopital de la Charite, covers the Wound with dry Plagets, Dofels, Compreffes, and a Sufpenforium. THE Lithotomifts of the Hotel-'Dieu drefs their Patients differently. In the firft Drefling (I. fupporethere is no occafion to ufe a Tent) they apply upon the Wound a Plaget covered with an Afiringent made with Bol. Armen. Vinegar, Cerat, and 0/. Rofatum. Afterwards, they make an Embrocation with 01. Rofatum upon the Belly, in the Groins, upon the Scrotum, and at the Circumference of the Wound; and then they apply upon the Plaget a fimple Comprefs, cut like a Horfe's Shoo, and covered with the fame Aftringent; the Whole being dipt in Oxycrat, a fimple Comprefs pierced to let in the Penis, covered with the fame Aftringent; and above that whole Drefingd a double Comprefs dipt in warm Ox crat. The whole is fupported with a Bandage, called the double T, Qthe z26 A Treat;e of the the Middle whereof is applied to the hinder and lower Part of the Lumbi, and the two Ends come about the Belly to be tied on the Side, by paffing one of the Ends into a Bandage, called the Collar, and which being tied behind the Neck, hangs down to the Navel. Afterwards, the Surgeon takes the Heads of thofe Bandages, which are between the Thighs, to pafs them above the Wound and Groins, one on each Side; and then he paffes them about the T, which ferves inftead of a Girdle, and ties them together on the Side oppofite to the Knot of the Girdle. Now the Surgeon mufl hinder the Patient from keeping his Thighs afunder; which he might do in his Sleep, and fometimes without minding it. But to prevent this, the Surgeon faftens them at a certain Diftance irom one another, with the Help of a Roller, the Middle whereof he applies to the upper and external Part of the right-Knee. For inftance, he pafles one Head under the Thigh, and the other above it; he crofles them between the Thighs, twif ting them twice; and then he pafles thofe two Heads above and under the left Thigh, to end at the external Part. That Bandage is called the Garter. BECAUSE the Urine and other Excrements fall into the Patient's Bed, they put under him a Sheet folded in feveral Doubles, and rolled at one End. That Roll lies on the right-Side, for inftance, of the Patient; and when that Part of the Sheet, which lies under the Patient, is fpoiled, they pull it on the left-Side, whilif they unroll Part of the Roll, that is on the right-Side. THE following Dreffings are alfo different from the former, becaufe the Surgeon ufes no longer any Aftrin Operations of SU YR G R Y. tY7 Afitringent, but covers the Plagets with a foft and fuppurative Balfam, laying above it a Plailter, and a Comprcfs in fix or eight Doubles, a Foot longand three or four Inches broad, in the Shape of a S ufp e nfor. AGA I N, the Surgeon changes the Balfams and Ointments, according to the Indications and the different Accidents that happen. Nay, he is fometimes obliged to make Injections into the Bladder fometimes to drefs the Patient very often, and at other times feldom: In many Cafes he ufcs no Bandage; and fometimcs he leaves the Wound without putting any thing to it. All thofe Differences depend upon the different Alterations in the Wound, and the adjacent Parts; but I fhall not mention'em, becaufe I fhould be obliged to explain them mechanically, and to aflign the Remedics proper for each of them; which would carry inme too far. Thofe who defire to fatisfy their Curioity, muft attend the Drefiings at the Hotel-'Dieu. BEFORE I make an end of thofe Dreflings, I mufl obferve that the Drefling of Women, is fomewhat different from that of Men. However the Surgeon ufes the fame Medicaments; but inflead of the Horfe Shoo, and the Sufpenfor, he makes ufe of a fingle and double Bandage in the Shape of a Cafe for Spetacles; and the remaining Part of the Cure is performed much in the fame Manner as in Men. THE Patients, that have been cut, are blooded, as Occafion requires: The Surgeon gives them Clyffers, gentle Purges, and different Potions, according to the different Indications and Accidents; and therefore it is proper for him to confult a wife and prudent Phyfician. 2 28 A Treaife of the T HE Surgeon muff prefcribe a very ftrif& Diet the firft Days, confining the Patients to Broth, and fone Spoonfuls of Jelly, to Diet-Drinks, and Rice and Chicken-Broth. At laft, he increafes their Diet by degrees, giving them a little Wine and a new-laid Egg, the Wing of a' Chicken, and other Aliments, as the Time of their Cure grows nearer. CH AP. XIX. Of the Stone in the LUethra, and the Operations proper for it. T HE calculous Concretions above-mentioned being united together, either in the Kidneys, or in the Bladder, and having formed a fmall Body, hard, folid, and brittle, which, as it increafes, occafions, as I have faid, great Pains, and Concuffions, that make it fall into the Bladder it follows that being toffcd up and down by the Urine, if its Diameter be proportioned to the Neck of the Bladder, it will get into the Urethra. A s foon as that fmall Body is in the Urethra, it flops the Paflage of the Urine; and the Patient firaining himfelf to void the Waters, makes a great Infpiration, and then keeps in his Breath to drive out the Urine. In that violent Ation, the Diaphragm, which is naturally vaulted in the Breaft, grows flat; and the Liver and Stomach are more impelled into the Belly: Thofe Vifcera comprefs the Inteftins, which prefs the Bladder on all Sides; and Operations of S U R G F R Y. 2129 and the Mufcles of the Abdomen do not a little contribute to it by their Contraction. THF, Bladder beinig preffid on all Sides, the Urine will be forced into the Canal of the Urethra; fo that the fmall Stone lying in that Canal, being continually impelled by a Column of Water, will move on by degrees towards the Middle, or the Extremity of the Urethra. IF the Stone is large enough to fill up the Canal of the Urethra, it will comprefs the Blood-Veffels of its fpongious Texture, and of the cavernous Bodies; which will occafion'an Inflammation, Irritations, and great Pains; and the more the Urine flows into the Bladder, the greater will all thofe Symptoms be. THE Surgeon knows that Difeafe, Firit, becaufe the Patient cannot void any Urine at all; Secondly, becaufe he feels a Pain, and very often a confiderable Tention in that Part where the Stone lies; and if the Surgeon handles it, he feels a hard Body in the Canal of the Urethra. T HE Urine being kept in the Bladder by the Stone, which flops the Canal of the Urethra, all the Accidents attending the Urine kept in the Bladder, will altfo attend the Stone in the Urethra; and therefore a fpcedy Remedy ought to be applied, in order to deftroy them all. IF the Stone is flopped at the Extremity of the Penis in the Fo/ffi, and if the Surgeon had preffed it behind to make it come out, without any Succefs, not even with a finall CuGrethra, bota upon account of the Inflammation and Bulk of the Stone, he muft not fcruple to make an Incifion in the upper Part of the Glans: That Wound is ibon Q. 3 cured.; 230 A Treat;fe of the cured; and by that means the Surgeon can pafs the Curethra behind the Stone, to make it come out. IN order to drcfs that Wound, the Surgeon wafhes it with warm Wine, and lays upon it a fmall Plaget covered with an agglutinative Balfam, and a Comprcfs crofs-wife, with a Hole in the Middle to let out the Urine; and the Whole is faftened with fome Turnings of a fiall Roller. BUT if the Stone lies in the Middle of the Urethra, and the Surgeon has endeavoured to no purpofe to make it come out, by prefling it behind,&c. it will not be amifs to injc6t fome Oil into the Penis: (I fuppofe, the Surgeon preffes ftill the Penis beyond the Stone, for fear it fhould return again into the Bladder.) Afterwards, he tries again to make it come out; and if all thofe Motions prove ufelcfs, he muft pceedily proceed to the Operation. SURGEONS do generally make an Incifion in the lower Part, or on the Side of the Urethra 3 but becaufe the Urine comes out thro' the Wound, and prevents the Reunion, it is not improper to make that Operation according to Mr. Thibaut's Pradice. THAT Surgeon holds the Penis between his Thumb and the two next Fingers, and then makes an Incifion with a ftrait Bifouri on the Side of the Penis, only in the Skin. Afterwards he uncoirers the Urethra in that Part where the Stone lies; and there he makes an Incifion in the Urethra, upon the Extent of the Stone, and almoft under the cavernous Bodies. THE Stone being uncover'd, he takes it out with a finall Scoop, and dreffes the Wound with a fmall Plaget cover'd with an agglutinative Balfam, with a circular Comprefs, and fome Turnings of a fmall Bandage. I think peratiOms of SURGER Y. 23I I think the Wound of the Urethra may be fpeedily cured by that Method of Operating; becaufe it lies almoft under the cavernous Bodies, to which it will foon agglutinate, and becaule it is not parallel to the Wound, and lies in a Place through which the Urine cannot pafs. T H E Patient muft have little or no Drink, that he may not void much Water, and confequently that the Wound may be lcfs wafhed with it. And therefore I think, it would not be amifs to probe the Patient immediately after the Operation, in order to empty the Bladder wholly; for the Urine is not a Balf am, which reunites that Part: On the contrary, we fee that it occalflons all the Diforders in the Fiflulas of the Perineum. CHA P. XX. Of the Phirnofis. B Y the Word Phiniofs is meant a Straitenitg of the 'Preputium, which prevents the Uncovering of the Glans. THAT Straitening is either natural or accidental. The former is, when a Man is born with that Difeafe; but becaufe it is not then attended with any Inmation, it does not prove dangerous. However, it happens fometimes that the Urine, as it comes out, lodges between the Glans and the Praputitium, and ftagnating in that Place, its Salts are united, and grow larger. Which cannot happen without their having a greater Number of Surfaces, and being Q 4- more 2 3 2 A Treat fe of the more able to make ftrong Imniprefflions upon the Glans, and the internal Membrane of the Preputiunm. And becauife thofe Imprefflions increafe as the Salts grow in Bulk and Quantity; it is plain they will occarfton a Pain, and that Want of Conformation will prove grievous in time. I have feen feveral People, who were born with a Phimofs,without being troubled with it; but I know a young Man of three and twenty Years of Age, who feels fo much Pain in that Part, that he dares not touch it; and his Shirt, tho' never to fine, does fometimes trouble him very much. THERE are two forts of accidental Phimoris, one natural, and the other malignant. The natural Phimoqs proceeds from the rubbing of the Shirt, or forne other like Caufe, which bringing an Inflammation upon the Glans and Praputium diftends the former, and firaitens fo much the latter, that its Extremity forms a circular Body, which hinders the Glans from being uncovered. THE malignant TPhinofis proceeds from venereal Difeafes. It happens fometimnes in a Gonarrhoea, for inflance; becaufe the virulent Matter, which continually runs all along the Canal of the Urethra, coming to the End of it, finds jtfelf in a Place fomewhat larger, called by Surgeons the Fof fa; and becaufe the Canal of the Urethra bends a little in that Place, it plainly appears from thence, that the Matter will be forced to flay longer in it, and that fome Part of it will always remain there. IF the thickeft and moft clammy Matter, flowing from the Jejicula feminales, the Proj/ate, &c. iii a Clap; (for 'tis a Miftake to believe that the gonorrhoea has its Seat only in the'Proflatxe The firy~ Operations of SURGERY. 233 firft and fecondary Veficule feminales, and all the Glands in the Canal of the Urethra, are infiltrated with the fame Venom ) I fay, if the Matter flays longer at the End of the Urethra, it will ferment; the corrofive Salts will be united together, and by that means grow more bulky, and confequently will be more able to tear and corrode that Part of the Urethra. T HE Extremity of the Urethra being thus corroded, as one may fee, and as it plainly appears by the great Pain, which the Patients feel rather in that Part of the Urethra than in any other; I fay, that Extremity will be the more inflamed, as the Corrofion is greater; and if the Inflammation comes to a certain Degree, it will attach the Glans and Praputium, and diftend them both, fo that the former will take up more Room; but the latter being ftraitened will cover the whole Glans, and fo will occafion a Phimojis. But if the Glans is not ufually covered with the Prxputium the latter will ftraiten the Glans, and make what we call a Paraphimois, which is a Difeafe quite contrary to that I am fpeaking of in this Chapter. THE Glans and Preputium being generally diftended, it follows that the Blood of the Veins will be ftopt there in Part; and the Arteries forcing, as it were, the Compreflion, will always convey a little Blood into the Glans and Prtputium: And becaufe the Blood does not return from thence in the fame Quantity, they will be diftendcd, and inflamed more and more. The Glans and Preputium being thus inflamed, the fmall nervous Fibers, which convey the Spirits into them, will be diftended, and violently moved by the leaft Impreffion; Z34 eA Treat~ of the iiq; fo that the leaft Bodies, which fhall touch thofe Parts, will occafion very great Pains. TH 0 S E Difecaics do alto frequently proceed from Chankers, Warts, &c. and even fomctimnies from corrofive and unfeafonable Remedies; but the Readers will difpenfe me from explaining how that happens, becaufe I ihould be obliged to repeat what I have juft now faid. THE Phimojis is known by the Account I have given of it5 and its Prognoflick is more or lefs dangerous, according to the different Caufes of thatDifeafe. The natural Phimojis has nothing in it, that is bad: It is only liable to Inflammations; but the malignant one, being frequently a Confequence of the Pox, requires a greater Caution. C F A P. AXXI. Of the Opebat"o? of the Phimofs. WH E N the Phimnofs happens to be natural, its Inflammation being the greateft A ccident, which however might be attcndcd with difmal Confequences, all Remedies, proper for Inflammations in general, ought to be ufLed: And becaufe Phlebotomy is the Spcciiick of all Inflammations, and is knowvn by all learned Surgeons to be the mofit fpcedy R erncmedy, it ought to be ufed immediately, and rcpeatcd more or lefs, according to the Nature of the Difreafe. THE \eelS being thus emptied, the Surgeon mufl relax the Preputirnm and the Glans, which arc Operatoms of SURGER Y. 235T are confiderably diftended. To that End, let him apply upon the affeded Part fome anodyne emollient Poultices, or Plaiffcrs, as he thinks moff proper. IF the Phimofis be a malignant one, he may begin with thofe Remedies; and becaufe there are generally finall Ulcers upon the Glans, whether they proceed from the Acrimony of the Matter, which flowing in a Clap gets between the Glans and Preputium, or are Shankers that have no Callofity in their Circumference, the Surgeon, in order to cleanfe thofe fmall Ulcers, muff introduce the End of a finall Syringe, and make Injedions. I have often cured a RPhimoJf with thofe Remedies, without being obliged to proceed to the 0 -peration. BuT if that Method proves unfuccefsful, and if the Surgeon handling the Preputium perceives by its Hardnefs that there are deep Shankersup on the Glans, he muft perform the Operation to difcover them, and to ufe proper Remedies. BEFORE he performs that Operation, he ought to mind the Place of Eletion, and the Place of Neceflity. The Place of Eledion is in the upper Part of the Praputium, without minding the Diftribution of the Veels. The Benefit arifing from thence, which confifts in conveying the Inflrument farther, and uncovering equally both Sides of the Glans, is to be preferred to the fmall Hemorrha4 gy of the Veins of the Preputium. The Place of Neceflity is to perform the Operation upon the Shanker, and on both Sides, if there are Shankers on both Sides. THE Surgeon knowing the Place, wherein he is to perform the Operation of the Phimofis, makes the 23 A Treatte of the the Patient fit upon a Chair and a Servant holds the Penis near the Pubes, whilft the Surgeon pulls a little the Extremity of the Preputium to make the internal Skin even with the external, and to remove all the Wrinkles, which might hinder him from conveying the Inftrument far enough. Surgeons do generally ufe a fmall Pen-knife having two right Angles near its Handle, almoff like a Wimble, and they put at its Point a fmall waxBall, to prevent pricking the Glans or the Praputium, when they convey that Infirument beetween them. But that Precaution is very ufclefs; and when the Inflammation of thofe two Parts is very confiderable, it is abfolutely impoffible to drive that Inftrument through upon the Flat, beyond the Ridge of the Glans; and it happens that when the Surgeon conveys the Inftrument, its Point pierces the fmall wax-Ball, and pricks the Patient, who feeling a Pain, makes fome fmall Motions to withdraw; and the Surgeon being refolved to perform the Operation, pierces the Preputium in that Place, and makes an End of the Operation, which is not half performed, and confequently cannot cafe the Patient, efpecially if there arc any Shankers. THIS happened to me once; and though I minded the Obfervations of good Praditioners, and thofe that are to be found in the beft Books, yet I perceived that I had committed two Faults. The firft was that, which I have juft now mentioned and the Glans was only half uncovered. But to fhew that I had carefully obferved the Precepts of the beft Surgeons, I pulled very much the Skin of the Penis, with a Defign to make a large Incifion, as it is ordered; and after my Operation, the Penis Operations of S SU RGERY. 237 nis happened to be uncovered almoft in its whole Length, there being ftill a Conftridion upon the Glans by the internal Part of the Praputium. To remove that Conftridion, which did not difcover a Shanker, for which I performed that Operation, I conveyed the blunt Branch of the Sciflars between the remaining Skin of the Praputium and the Glans; and when I perceived that it was be. yond the Glans, I cut and uncovered a pretty deep Shanker, having its Edges raifed and hard. I cured it with a fixteen or fevcnteen Days Salivation, excited by three gentle Fridions, and the other Remedies that are proper in fuch a Cafe. For 'tis a Miftake to fancy that the Purges and Diet-drink prefcribed for fuch Shankers, can cure them. The Patient has ftill the Pox; and 'tis no Wonder if we fee fo many Children troubled with the KingsEvily Scurvy, Confumptions, and other Difeafes of that Nature. To perform the Operation all of a fudden, withbut running the Hazard of committing the firft Miftake juff now mentioned, Mr. Lapeyronie has made an Addition to the Biflouri for Hernias, which appears to me effential. Inftead of the Screw which holds the Blade upon the Cannula, he has added to it a Screw, which has a great Hold, and may eafily be removed; fo that a Surgeon may introduce that Biflouri with the Cannula, beyond the Glans, without running the Hazard of pricking the Patient. Afterwards, he takes off the Screw, and gently withdraws the Cannula, fo that the Blade being alone between the Praputium and the Glans, he takes it by its fmall Plate with his right Hand and the fore and middle Fingers of the left Hand, 238 A Treatie of the Hand being applied on both Sides of that Part, where he thinks the Point of the Inftrument will come out, he pierces the Prxputium, and immediately conveys his fore-Finger behind the Back of the Bifouri, which he withdraws, and fo makes an End of the Operation. PERHAPS that Inftrument will not be approved by every Body; But I may fay to Mr. Lapeyronie's Praife, that it appears to me much better than the ufual Pen-knife; that the fmall wax-Ball at the Point of this laft Inftrument is liable to the Inconvenience abovementioned, efpecially when the Conftrition of the Praputium is attended with a confiderable Inflammation; laftly, that if I had made ufe of that Inftrument, when I performed the Operation, of which I juft now gave an Account, I fhould not have committed a Fault, which the moft dexterous Surgeons cannot avoid in a like Cafe. BEFORE I make an end of what concerns that Operation, it is not improper to obfcrve, that moft Praditioners advife to pull very much the Skin of the Penis, when the Inftrument lies between the Preputium and the Glans, in order to make a larger Opening. Mr. Petit is againft that Method, becaufe the Surgeon by that means uncovers the Body of the Penmt; which is needlefs, fince the Difeafe does not lie in the Body of the Pents, and becaufe that Method puts the Patient in great Pain, and cuts out more Work for the Surgeon than there is occafion for. He alfo fays, that if the Skin is not fufficiently pulled, the Surgeon cuts only the internal Skin of the 'Prxputium, and does not cure the Difeafe. To avoid thoic Inconveniencies, the u Surgeon Operations of SURG E RY. '239 Surgeon ought to make the internal Skin of the Praputium level with the external, as much as poffible, and to cut no more of the one than of the. other. WHEN the Operation is performed, it frequently happens, that the IFrnun does flill very much pull the Glans. In fuch a Cafe, Mr. Arnaud advifes to cut it: It is eafily cured. THE Drefling Of that Difeafe being the fame as for the Paraphrimojis, I mhall defcribe it in the following Chapter. CHAP. XXII. Of the Paraphimofis. r HE Paraphimofis is a Difeafe quite contrary to the 'thimonfs, becaufe in the latter the Prdputium conceals the Glans in fuch a Manner, that it cannot be uncovered. But in the ParaphAmonis, the Praputium is fo much drawn back and diftended beyond the Glans, that 'tis impoflibic to bring it over. THAT Difeafe proceeds generally from the fame Caufes as the 'Phimornis, epecially in what concerns venereal Difeafes. But it happens fometimes by a violent Effort, as when the PrAputiuum is naturally fomewhat narrow, and difcovers but one half of the Glans. If it be then pulled towards the hinder Part of the Penis, as foon as it comes beyond the Glans, it does fo conifringe the Penis, that the Glans being immediately fwelled, prevents the Redudion of the Traputiumr. ON 240 A 7'eatfe of the ON the firft or fecond Day of that Difeafe, the 'Praputium is turned back as I have juft now faid, and makes a thick Body, which fqueezing the Glans, difftends it very much: The Skin of the Prrputium is alfo confiderably inflamed and fwelled. But becaufe the Blood running into the Glans has hardly a free Paffage any longer, it flows in greater Quantity into the collateral Veffels; and thofe Veffels conveying it into the Skin of the Praputium, which is the Caufe of the Conftridion, it accumulates there in greater Quantity and diftends that Skin very much whereby the Confitridion is encreafed. THE Skin of the Prxputium being thus fwelled, the fmall nervous Fibers reaching to it are very much diftended, and confequently very fufceptible of Irritations; fo that the Spirits running plentifully into that Part, occafion a Pain, which flhaking the fmall Nerves, repels the Spirits towards the Brain. And becaufe thofe Irritations laft as long as the Difcafe, the Nerves of the Penis give always a free Paffage to the Spirits; which ftraitens the 'Prrputium in feveral Places, and occafions four or five Edgings, that make as many Conftrikions, as it happens on the third and fourth Days, and fometimes fooner, or later, according to the Violence of the Difeafe. Thofe Rifings comprefling the Veins and the lymphatick Vefiels, the latter are very much diftended by the Lympha, and the former by the Blood; fo that the lymphatick Veffels being very numerous in the fatty Cells of the Praputium, they diftend it, and form a Tumor like a kind of a Circle beyond the Glans. THE Conftrifion not being fo confiderable on ~ both Operathons of SV R dF iRy. 4i both Sides of the lower Part,6f the Prkputiump and the Skin beifig there fomewhat loofer, the Lyni. pha flows into it in a greater Quantity, and gathe i ing in it by degrees, it occaftons a Diftention if thai Place, and a very large Tumor, fonaewhat like atid ther Glans. THOSE Tumors diftending the Skin of the Prwa: putium more ifll, anid increafing the Inflammation; the Heat increafes proportionably; and the Artem ries affording always a little Blood, contributt alfd to heat that Part. The Heat therefore grows at laft fo confiderableý that it rarifies the Lympha; which is colleted in the fatty Cells; and difflpa" ting its watery Particles, nothing but a tranfparcnt Body will remain. BUT the Blood being flopped in the Veins; s s have faid; it flays there, and its Serofity has a fufi ficient Time to feparate from it, and, to philtrat' thro' the Pores of the Coats of the Veins, id or der to diffufe it felf likewife into the fatty Celhg and to increafe fillithe Tumors above-mentioned, efpecially that, which lies in the lower Part of the Glans. APTER What has beerr faid, there is nd need of mentioning the diagnoftick Signs of the Paraphimofjis. The Actount I have givent of it, is mnorei than fufficient to diflinguifli that Difeafe; but itd Prognoftick is more or lefs dangerous, as the Ui-. flammation is more or lefs confiderable; and tha& which is occafioned by venereal Difeafes mufl needs be more dangerous than the others. ALL Authors fay, that when there is a confide4 rable Inflammation, the Penis runs a great hazard of being mortified; and according to this Notion; fome are againft Topicks; the good EffdcT whereof 24Z A Treatife of the is too flow for a Dieafe, which requires a fpeedy Help. On the contrary, they advife to make with the Point of a Lancet fmall Incifions upon the interna Membrane of the Praputium. Others are for farifying the Tumor lying in the lower Part of the Glans, to difcharge the Part, and prevent a Mortii fication. 'TIs true, that when the Paraphimofis is come to the Degree, I have fuppofed, the Penis is in a very bad Condition and the Liquids being flopped every where, there is ground to fear a Mortification. However, I have had two fuch Difeafes under my Cure, which were attended with all the Accidents above-mentioned ( for the Obfervations they afforded me, have enabled me to defcribe the Paraphimofjs fo exafly.) And yet I perceived in them no Difpofition to a Mortification. I was rather afraid that the Wound made at the Foot of the Glans by the Conftri&ion, fhould grow fo deep, that fome Atteries would be opened, which would have given me a great deal of Trouble. CH A P. XXIII. Of the Operation of the PARAPHIMOSIS. S I N C E the Inflammation and Tenfion of the Prsputium and Glans occafion all the Accidents above mentioned, the Surgeon muft endeavour to empty the Veffels, and relax the Parts, that are contrafced. But before he tries any Remedy, he muft uli his utmoft Endeavours to reduce the Prapu Operations of SUR GER Y. 24 3 Praputium. In order to it, he mult confider what hinders it from coming over; and becaufe the Glans is very much diftended, and its Bafis jets out, which is an Obftacle to the Succefs of the Operation, he muff leffin the Bignefs of the Glans by preffing it length-wife. AUTHORs difpute about the manner of making that Reduction; for fome will have the Surgeon to convcy the fore and middle-Fingers of both Hands behind the circular Diflention above-mentioned, and to draw it at the fame time towards the Extremity of the G!ans, without touching the Glans, efpecially about its Extremity; becaufe if it be touched, it will be more difllended. TH OSE Authors offend againft the Precept, I have given, which confifts in leffening the Bignefs of the Glans, by drawing it longer; and if the ParaphimoJis be attended with all the Accidents above-defcribed, it is abfolutely impoflible to reduce it in that manner. OTHERS advife the Surgeon to apply both Thumbs upon the Sides of the Glans, (I always fuppofe the fore and middle-Fingers to be behind the Diftention of the Praputium ). to leffen its Bignefs. THESE Authors offend alfo againft the fame Precept; for if they lcffen the Bignefs of the Glans on the Sides, they increafe it at the fame time in its upper and lower Part; nay, they increafe it as much as they leflen it on the Sides. That Method therefore cannot be fuccefsful. LASTLY, other Authors reje&l thofe two Opinions, and fay, that thole, who advanced them, were not very expert Surgeons; becaufe, if they had pra&ticed -that Operation, they would have known that the Glans is fo much fwellcd, and fo hard, that whate R z ver 244, A Treatife of the ver Endeavours be ufed to cover it, 'tis impoffible to render it wider by pufhing againft the Extremity of it. Wherefore they will have the Prputium to be brou t over the Glans, with the fore and middle Fingers, as I have faid, whilft the Glans is repelled with both Thumbs, to reftore it to its natural Situation. 'TIs true, that in the Confirifion the Glans is veo ry much fwelled and very hard; but notwithflanding its Hardnefs, if it be as fitrongly repelled as is neceffary, its Extremity will come nearer the Circle of the Glans and widen it. Tho' it grew wider but by one Line, it would be fill fufficient to prevent the Redudion. WHEREFORE, in order to reduce the Glans, the Surgeon muft leffen its Bignefs, by drawing it longer. Mr. 'I'etit does it with a Fillet fplit in the Middle, which he applies about the Glans, like an unitive Bandage. Afterwards, he brings the Prrlputium nearer, in the manner above-mentioned. IF that Method, tho' very ingenious, cannot fucceed, aprudent Surgeon fhould not leave the Patient, before he has performed the Operation, that is proper in that Cafe, in order to bring the Praputium to its natural Place. But the Patients are always afraid of Incifions, and will not allow of them 'till they know there is no other Remedy. THE Surgeon mufft therefore empty the Veffels, and relax the great Diftention; which may be effeded by frequent Phlebotomy, and the Application of emollient Poulti ces. But he muff obferve, that in all thofe Difeafes the Penis ought not to hang down; for by that means the Inflammation and Di.ftention are frequently increafed. The Surgeon muit therefore ufe a Sufpenj/rum, which is a compounded Bandage, Operations of S v R G ER Y. 24T Bandage, and keep the Penis faltened to one ofthe Groins with a Scarf, which is nothing elfe but a Comprefs fomewhat long, tied to a Girdle; taking care to remove the Pentzs now and then frin one Side to the other, for the Eafe of the Patient. Two or three Hours after, the Surgeon takes off that Dreffing, wipes the Penis very clean, and makes a new Trial to reduce the Prneputium: And if fome Applications of thofe Remedies prove ineffe&ual, he muff neceffarily proceed to the Operation, about which Authors differ, as I have already faid; fome making Scarifications in one Place, and others in another. WHEN I had under my Care the two Paraphimoa fes above-mentioned, I made Scarifications with a Lancet, according to the ufual Method. There came out but four or five Drops of a limpid and reddifh Serofity; and I perceived at the opening of every Scarification a very tranfparent Body, like a Jelly; and the Fingers with which I held the Lancet, felt a fmall Noife, when I cut that Body. Confidering that the Incifions, I had made, did not at all relax the Confiridion, I thought, fome Suppuratives, refolving that tranfparent and congeal'd Body, might unbend the Penis, and facilitate the Redution of the Praputium. But I was furprifed to fee the next Day the Glans more diftended and inflamed, and the Scarifications dry and contraded. I had recourfe again to Phlebotomy, and the ftrongeft Emollients, which removed the Tenfion at laft, and brought back the Preputium to its natural Situation, without the Ailiftance of my Hand. SOME Surgeons feeing the Bignefs of the Glans, and being fenfible that its Head prevents the Redu~ion of the Praputium, are for making ScarificaR 3 tions 2.46 A Treat re of the tions round the Glans, to empty it, and to facilitate the Operation by that means. THAT Notion appears fpecious; but a Surgeon well acquainted with the Nature of the Difcafe, will plainly fee that the Diftention of the Glans being only occafioned by the Conftri&ion of the Praputium, it would be in vain to pretend to cure the former, before he has removed the latter. Befides, if he confiders the Struture of the Glans, and is fully convinced that it is of a fpongious Texture, which cannot be diftended without being full of Blood, he will by no means make Scarifications upon its Head. IN order to perform the Operation of the Paraphimofis, Mr. Petit takes a Biftouri fomewhat crooked: He conveys that Infirument, (its Back being turned towards the Penis,) between the Penis and the Praputium, under the Conftriaion and the Furling of the Preputium, and raifing the Point of the Bifouri, and lowering the Wrift, he cuts the firft Furling: He cuts likewife the fecond, the third, and the fourth, if there are any; in a Word, 'till the whole Conftriftion be removed; which he knows, when he feels no longer a tranfverfe String; and then the Pr&putium is more moveable. I F the Franum it felf is very much diftended, and confirains the Penis, Mr. Arnaud advifes to cut it, without fearing any thing. THE Surgeon wafhes the Penis with warm Wine, and reduces the Preputium, which is cafily performed. Afterwards, he makes an Embrocation with warm Oil of Roles upon the Penis, in the Groins, and upon a Part of the Belly. He applies upon the Penis a Plaifter of cut with two Heads, that it may be more eafily adapted to the Penis. He lays over that Plaifter a fmall Operations of S u R GER Y. 14# fmall Comprefs of the fame Figure, and dipt in a proper Liquor. He covers thofe two Pieces with a iinall and fingle Comprefs, made in the form of a Crofs of Malta, with a Hole in the Middle for the Paffage of the Urine; for this laft Comprefs muft be applied immediately upon the Extremity of the Penis. He fupports the Whole with a Fillet, cut at one End, according to its Length, to form two fmall Heads. Now he muft put the above-mentioned Sufpewforium and Scarf of the Penis, and tie them to a Girdle fupported by a Napkin doubled in three Folds, according to its Length. IT is not improper to make the following Days Injetions between the 'Praputium and the Glans, with warm Wine, &c. CHAP. XXIV. Of the Fiflula in Ano, and Abfceffs, which happen in that Part. T HE Fiflula is fo called, becaufe it has a long and narrow Cavity, like that of a Flute. THE general Definition of a Fiflula is, an Abfcefs, whofe Bottom is much larger than its Orifice, commonly attended with a Callofity, and from which an acrimonious and ferous Matter flows. A Fiftlula is always a Confequence of an Abfcefs, and confequently it may happen almoft in every Part of the human Body, efpecially in thofe Parts, that are very fat, or imbibed with Humours. SINCE a Fiflula is the Confequence of an Abfcels, it follows that whatever can produce an Abfcefs, will be the true Caufe of a Fiflula. R 4 THE S8 A re ate/fe of the Tig A4nus is fubjett to two Sorts of Abfcecffes. The firft happens all of; fuddens and the fecond, F4led the hfiJula in Ano, is formed flowly. TUE firft Abfcefs begins with a Kind of Tumor, vhihih grows very confiderable, and occafions a great DiLforder in a fhort time. 1 T begins at firfl by a fmall Tumor, very hard, and npt bigger than the Finger's End. That Hardefs is very deep, and furrunded with a Rednefs: It frequently happpns that nothing is to be feen in,th Skin but an EryfPelas, the Heat whereof is Io great, that in four and twenty Hours it will pro4uce an Abfcefs, whofe Confequences will prove dreadful, unlefs they be timely prevented. The Pains which the Patient feels, are fo fharp and fo violent, that they occafion a Fever, and many other Accidents. THE fccond Abfcefs is particularly known by the Name of Fiflia. A Fijlula is formed more flowly: It begins with a Rednefs without a Timor; but the Patient feels a Pain, and' the Surgeon perceives a Hardnefs. The Tumor appears in procefs of Time, and at laft it furrounds a whole Side pf the Anau. WI IE i the A bfcefs is formed, the Accidents feer to be pver, and the Matter firiving to come out, piercps the Intefltin rather than the Skin, becaufe the 6frmer is more tender, and makes lefs Refiftance than the Skin, which is of a clofe and firm Texture. But be;aufe the Difeafe encreafes 4aily, the Matter which grows mnore and more corrofiye, daily makes jts Way through new Paffages on the Right and on the Left, and the Skin is piprccd by one or many fmlallHoles, out of which a feqous Matter flows, Operatons of Su R E R Y. 149 Fr appears from this Defcription, that the Fiflulas in Ano are of different Figures, according to their different Degrees of Malignity and Growth and therefore they have been called by different Names, according to their different Kinds. THERE are in general two Sorts of Fiflulas in Ano, a compleat one, and one that is incompleat. The compleat Fifula has two Orifices, one in the Inteftin, and another in the Skin. THIS Sort of Fifula is known by conveying a Stilet, with a Button at the End of it, into the external Orifice, and the fore-Finger into the Anus; and if the Stilet be felt with that Finger, there is no longer any Reafon to doubt of there being two Orifices. THE incompleat Fiftula has but one Orifice, either in the Inteftin, or in the Skin; and from that Difference it receives different Names. IF the Fifula opens into the Inteffin, and no Orifice happens outwardly, our modern Operators call it blind, and internal. On the contrary, they call it blind, and external, if it opens outwardly, and has no Orifice in the Infide. A Surgeon knows that there is a Fiflula of the firft Kind, when the Patient feels a Pain, and a Sort of Heat in the Anus; when the Anus is red and excoriated, if the Fiflula is fomewhat old; and when the Patient has an Itching, and confequently a Defire of going to Stool; And if the Surgeon conveys his Finger into the Anus, he will know that there is an Orifice by reafon of its Unevenncfs. THE Tumor which appears outwardly, attended with a fmall Inflammation, in which a kind of Fluctuation is fometimes felt, and the Pus coming out with and after the Excrements, are a further Sign of 25 0 A Treatife of the of an Ulcer near the Anus, which opens into the Cavity of the Inteffin. IT is no very difficult thing to explain all thofe Symptoms; and it may be faid that the Salts of the Matter, if grofs in any the leaft Degree, will flimulate the Inteftin, &dc. which will be attended with Pain, and the Heat and Rednefs will be the Confequences of the Compreflion of the Veffels, that furround the Ulcer. The Excoriation can only proceed from the Effufion of the Pus, the grofs Salts whereof bruife and tear thofe Parts on which they pafs. The Fibers of the Inteftin being thus torn, there will be a Reflux of the Spirits towards the Brain, that will be quickly attended with an Influx of the fame Spirits towards the aff'eed Part; and confequently the Patient will have an Itching, and a Defire of going to Stool, which is called a Tenefmus, &c. THE Signs, by which we know the fecond Sort of Fiflulas, called blind and external, are very plain, fince we fee an Orifice outwardly, and it appears by the Probe that there is none inwardly. TH E Matter of the Ulcer may likewife corrode on all Sides, and open new Paffages in the Circumference of the Ulcer, which are called by the Operators Sinus's. The Surgeon may know them by the Probe, the Plenty of Matter, and its different Alterations. C H A P. Operations of S v R G E R Y. 2 r ++++++++++++++++++++++++++++++++++++++++++++++ CHA P. XXV. Of the Operation of thofe AIceffes, which happen in the Anus. B E FORE I explain the Method of performing that Operation, I mutt obferve that it.will not be improper to advife the Patient to make Water, in order to empty the Bladder, which the Operator might otherwife be apt to pierce. Betides, thofe upon whom that Operation is performed, do not generally make Water but eight or nine Hours after and if the Bladder was full, it would be very troublefome. The Patient muft be told of it, that he may not be furprifed, if he cannot eafe himiclf by the coming out of the Urine. CARE muft alfo be taken to make him go to Stool; and to that End, he muff take a Gliftcr one or two Hours before the Operation, to dilute the Matters contained in the Inteftin, and to force 'em to come out. And becaufe the ReHum, during the Operation, fuffers an Irritation, which makes the Spirits flow back towards the Brain, and that Reflux is quickly attended with an Influx towards the Inteftin, the Patients have a Kind of Tenefinus. But becaufe they generally void no Excrements, they mufft not be fuffered to go to Stool. BESIDES thofe Precautions, the Surgeon muff alfo take care to put the Bandage, that he may not be obliged to flir the Patient after the Operation, for the Reafons to be mentioned hereafter. Mr. Arnaud's Bandage does fully anfwer our Intentions. Here follows a Deicription of it. THE Sy z A Treat;fe oJ the TH; Surgeon folds a Napkin in four Folds, and applies it about the Body of the Patient, like a Girdle. He fupports that Girdle with a Scapulary, fplit only in the Middle, and as much as is neceffary to leave a Paffage open for the Head. He fows that Scapulary to the Girdle behind, and in this laft Place, he fows three or four Fillets, which will be of Ufe. AFTERWARDS he takes a Lift of five or fix large Finger's Breadth, and about an Ell long: He cuts it into two, according to its Length, excepting eight or ten Inches of it, at one of the Ends, to which he muff fow three or four fmall Fillets, that will ferve to make Knots behind, With thofe that are already fowed to the Napkin and Scapulary And by this Method the Surgeon will be able to change the Bandage as often as he pleafes, and.to ftraiten it, without flirring the Patient. THE fixed Point of the Bandage is direftly over the Shoulders which makes the Excellency of it, becaufe the Bandage being faft, does very much comprefs the Drefling. THE next thing is to place the Patient in a proper Situation, in order to perform the Operation rightly and fafely. All Authors advife to lay him down upon the Edge of a Bed, and to put a Bolfter under his Belly, in order to raife his Buttocks, which muff be turned towards the Light. THOUGH that Situation feems to be a proper one, yet it is liable to fome Inconveniencies, which prevent the Safety of the Operation. For if the Surgeon opens fome confiderable Veflel, upon which he cannot make a Ligature, nothing but the Comprefiion can flop the Blood. And if the Surgeon Sflops it with fome Pieces of Linnen or Lint, and faftens Operations of S u R G E R-Y. T53 faftens the Bandage; that Compreffion, when the Patient is put to bed, will change its Place, and the Veffel will afford more Blood than ever. IN order to avoid that Accident, Mr. Mery, Mr. Arnaud, Mr. Petit and Mr. Thibaut advife to bring the Patient to the Edge of his Bed, to lay him down upon his Side, having his Buttocks prominent and his Thighs fomewhat bent, laffly in a Situation not unlike that of a Perfon, who takes a Glifter in Bed. THE Drefling being applied in that Situation, and the Bandage well faftened, the Patient does not change his Attitude: He only moves forward in his Bed and the firft Motion he makes to lie more eafy, is ftretching his Legs, whereby the Bandage is ftill more firaitened; and the Veffel more ftrongly compreffed. LET us proceed to the Operation of the inflammatory Abfceflfs, which happen in the Anus. THOUGH the Surgeon touches outwardly a fmall Tumor very hard, under which he feels no FluCtu ation, yet he muff not flop there 3 but he muft convey his fore-Finger to the Edge of the Anus, or Orifice, and feel that Part, where he fufpets the Abfcefs may lie: And if he feels a Hardnefs every where, he applies upon the Tumor a maturative Poultice. THE Surgeon muft not leave the Poultice very long upon that Sort of Tumor, the Abfcefs is quick, ly formed; for thould he leave it on till he felt a Flutuation on the Out-fide, the Abfcefs would occafion fo great a Diforder, that it would be, incurable. THE Operator muff therefore take off the Poultice two or three Hours after he has applied it, wipe the Skin and his Fingers, and convey again the fore 25T4 f A Teatie of the fore-Finger of one Hand to the Edge of the Anuz, or its Entrance, and the fore-Finger of the other Hand upon the external Tumor; that with the Help of thofe oppofite Motions he may be fatisfied whether there be any Pus. A T that very time he muft thruft a Lancet into the Middle of the Hardnefs, which appears outwardly, without taking off his Finger from the Infide of the Anu s; and he muft thruft the Lancet to the very Place, where he thinks the Abfcefs lies. There he makes a finall Motion, by railing the Point of the Lancer. A N becaufe the Pus lies always very deep in thofe Phlegmons, and a great deal of Blood always comes out, which mixing afterwards with the Matter of the Abfcefs, makes the Standers-by believe that the Surgeon has opened the Part, before the Abfcefs was ripe, and contequently before there was any Pus; Mr. Arnaud, that great Surgeon, advifes to put a Spoon under the Lancet, and to prefs the Tumor a little, to make a little Matter come out thro' a fmall Out-let left open under the Lancet, by drawing it back a little, and lifting it upwards from the Point, to make room for fome fmall Quantity of Matter to iffue out; which is a Precaution a Surgeon ought to take in all the Abfcefles he is obliged to open, that he may by that means fecure his Reputation from Calumny,and the Ignoranceof the Vulgar. THE moft learned Surgeons in Europe, whom I quote fo often, and whofe Difciple I am proud of being, could not avoid that Calumny, and have frequently performed thofe Operations in the Prefence of certain Surgeons, who were grown old in their Profeffion. As foon as the latter faw the Blood, they condemned our Operators, and told them in a reproachful Operations of S U R GE R Y. i proachful Manner, that they were very fond of cut. ting without any Neceffity. WHEN the Surgeon has drawn a fufficient Quantity of Pus, to fhew that he is in an Abfcefs, he withdraws his Lancet, cutting ftill in a ftrait Line what happens to be over its Edge. Afterwards, he puts his Finger into the Orifice, to dilate-the Seat of the Diftemper; which he can eafily do, becaufe the Pus has occafioned a Vacuity in that Placee And without taking off his Fingers from the Infide of the Abfcefs, he conveys by their Means Sciffars or a Biflouri blunt at the End, to enlarge the Orifice according to its Length, I mean, by going along the Anus. TH E Defign of a good Surgeon being to make the Bottom of an Ulcer very narrow, and its Orifice very wide, he muft not be contented with that firft Incifion; and to anfwer perfe&ly all the curative Indications, he muff make two other Incifions crofs-wife, taking Care to remove with Sciffars pointed at both Ends, and with a Biflouri all the hard and callous Bodies. To drefs that Sort of Abfceftes the Surgeon puts in three or four large Tents tied with a Thread. He puts the firft Tent at the Bottom of the Abfcefs, and places the Thread at one of the Angles, where he muft remember that the firft Tent lies. He does the fame with the others, and puts their Threads in a certain Order out of the Wound, that one may Fy the next Day, this is the firft, this the fecond, &dc. But becaufe thofe Threads may be diforder'd, it will not be improper to make them of different Colours, or to diftinguifh them by feveral Knots. All thofe Precautions are neceffary, that the Surgeon, when he removes the Dreffing, may not take off the firft Tent 26 ATreat;e of the Tent intlead of the laft-; which. might oceaflon an Hemorrhagy. O VE R thefe large Tents the Surgeon lays fome Pieces of Linnen, and Lint-Dozels, railing them fufficiently, that the Compreffion may be greater, And before he lays the remaining Part of the Drefling, he muft take care to draw a little the Thread of the firft, by which Mearis all othcis will be more compreffed. AFTERWARDS, he mufft lay over that whole Dreffing fome narrow and graduated Compreffes, and fupport the Whole with the Bandage above deferibed; tying the four Fillets behind the Back, and paflling the two Heads between the Thighs, to tie them to the Girdle, one on each Side. And becaufe that Bandage ought to be very tight, the Sutgeon lays fome Compreffes in the Groins, for fear of bruifing them. HE bids a Servahtt hold his Hand upon the Dref. fing, if fome Veffels are opened; and that Servant muff prefs towards the Veffel: To that end, the Operator is to place him right, by holding his Hand over his. C H A P. XXVI. Of the Operation of the Fiftula in Arid. D EFORE the Surgeon undertakes the Operatior.) of the Fiflula in Ano, he ought to be perfet&ly acquainted with the Nature of that Difcafe; and becaufe the Probe is the fafeft Way to know all its Complications, I fhall begin with it. IN order to probe a FJf/ula in 4Ano, the Patient Inuftf be brought to his Bed-fide as I have faid, fpeak;** ing. Operations of SUR G ER Y. 217 Ing of Abfceffes in the Anus. Afterwards, the Surgeon keeps the Buttocks afunder, that he may eaftly introduce the fore-Finger into the Anus, having greafed it with Butter, or dipt it in Oil. For it is a general Rule, never to drive a Probe pretty far into a Fiflula, that lies in the Circumference of the Inteftin, before the Finger be in the Anus becaufe the Intcftin being generally bare and deftitute of Fat,the Operator would run the Hazard of piercing it in a Place lying under the Orifice occafion'd by the Abfcefs; whereby the Operation would become either ineffedual or more painful. IN the next place, the Surgeon brings the Buttocks near one another; for their Diftance changes the Diredion of the Fijfula, and he might think that the End of the Probe is at the End of the fiftulary Channel, becaufe he could drive it no farther; and it wou'd be frequently flopped by an Angle occafioned in that fiftulary Channel by the Difiance of the Buttocks. THE Surgeon pufhcs the Probe gently, with feveral fmall Motions; and if he perceives that it reaches much farther than the Finger, which is in the Anus, he muft give over the Cure j for it would be ineffectual, and frequently dangerous. I T would be incffetual; becaufe the Surgeon not being able to take out the Bottom of the Fifu/a by the Operation, it would continue to gleet, and be quickly attended with a Relapfe. IT would be dangerous; becaufe, if the Operator, cutting beyond the reach of the Finger, fhould open fome confiderable Artery, he could no longer flop the Blood, and the Patient would quickly die. Mr. de la Charriere has infcrted in his Operations an Obfervation, which was communicated to him. I think it will not be improper to fet it down here. A Woman, fays he, of fifty Years of Age had been S trou 25 8 A Treat'ie of the bled with a Fifula in Ano for the Space of 5 Years. The great Pains fhe endured, made her refolve upon the Operation. The Surgeon, a very able Man, was a long time doubtful whether he fhould undertake it becaufe he could not find the Bottom of the Fiflula, and was afraid of not fucceeding in fuch a dangerous Operation. But at laft, being fenfible that fhe could not live long in that Condition, he ventured upon the Operation, of which fhe died nine Days after. He opened that Woman, and found that the Fiflula had affeded the whole Rectum as far as the Colon. IF the Orifice of the Fiflula was too fmall to probe, and to dif over the other Sinus's, the Operator muft ufe a prepared Sponge, which by diftending it felf, will open the Way, dilate the fiftulary Paffage, and inable him to fee all the Cavities. IF the Orifice, which appears in the Skin, makes a Conftriftion, which cannot yield to the Sponge, as it may happen by reafon of the clofe Texture of the Skin, the Surgeon muft dilate it with a Biflouri 3 for all poflible care ought to be taken to have a perfeat Knowledge of the Difeafe. According to this Notion, we ihall place the Patient in many different Situations; for though I have faid,,that lying upon the Bed-fide is the fafeft Situation for the Operation, yet I don't deny but other Situations may help us to find out fome new Cavities. IF the external Orifice of a Fiflula fhould appear upon the Buttock, I mean, if it was at a great Diftance from the Anus, and if the Surgeon fhould perceive by the Stilet, - that the Canal goes floping towards the 'Anus, and fomewhat fuperficially; laftly, if the Stilet flop all of a fudden, the Operator has good Ground to believe, that the Seat of the Difeafe does not lie there, he muft, without loing any Time, take a Probe grooved Oprations of S u R G E R Y. 2J5 grooved and open at the End, which nay ferve foi a moment inflead of theFemalc-Condu&or, and convey it upon the Stilet, which on this Occafion imitates the Male-Condutor. And when the grooved Probe is at the End of the Stilet,. the Surgeon muff take off the latter, and turn the Groove of the Probd towards the Skin, to convey into its Groove Scifhars or a Bifouri, in order to cut whatever happens td be above it. Afterwards, the Surgeon dreffes that Wound, dilating it very much; and the next Day he comes to work again, to examine the Fiflula, as I have juft now faid. THIS Method ought to be ufcd in thofe fiftuloiU Abfceffes, that have a fmall Orifice, which muftt bd dilated. Tho' it has been lately propofed, yet we are indebted for it to Mr. Arnaud: He is the firft Inventer of grooved Probes, opened' at the End, and the firft who compared them to the Male-Conductors in that Sort of Wounds. WHEN the Surgeon is thus thoroughly acquainted with the Nature of the Difeafe, he muff refolve upon the Operation. In order to perform it, he ought td remember all the Circumfiances, which I have mentioned, fpeaking of the Abfcefs in the Anus; and having purged and blooded the Patient feveral times, &Ce he muft bring him to the Bed-fide, as I have faid above. TH ERE are two Ways of performing the Operation. The firft confifts in conveying a Stilet into the external Orifice of the Fiftula, and fo out at the Anus, and then cutting all that lies between the Anus and the Entrance of the Stilet. ACCORDING to the other Method of operating, the Surgeon conveys a grooved Probe into the Fiftula, and brings the End of it as near the Anus as poflible. Afterwards, he cuts with a Biflouri or Sciflars whatever happens to be above the Grooveo S z TH 2 6o A Treatife of the T H t firft Method is the beft, the fafeft, and leaft liable to a Relaple. But if the Inteftin was pierced too far, the Surgeon muff make the Incifion above the grooved Probe; becaufe too much of the Inteftin would otherwife be cut off. WHICH VTay foever the Surgeon performs that 0 -peration, he muft always make the external Incifion much larger than the Bottom of the Sore; and if he refolves to ufe the Stilet, he conveys the fore-Finger, greafed or oiled, into the Anus, and with the other Hand he introduces the Stilet into the Fiflu!a; and when he finds with the Finger and Stilet that Part of the Inteftin, which- is pierced, he muff make another Hole in it with the Stilct, fomewhat above the Hole occafioncd by the Difeafc. Afterwards he muff conVey a little the Stilct into the Inteftin, direfting it with the Finger that is in the Anus; and without quitting hold of the Stilet, he bends it to make it come out in part through the Anus, and to form by that means a kind of Loop which he muft not draw too much, for fear of tearing the Inteftin. AFTERWARDS, he takes both Ends of the Stilet, that come out 3 and with a Biflouri fomewhat crooked, the Blade wlhrccof is faftencd to the Handle with a Fillet, he cuts and takes off whatever is contained within the Loop of the Stilet. AFTER that Operation, the Surgeon muff wipe the Blood, and fee whether he can difcover and open fome other Paffages. Afterwards, he conveys his Fingers into the Wound, to feel the Hardnefs and Callofity. Mr. Arnaud takes off Part of it with the Biflouri; and then with pointed Sciffars, conveying them into the Callofity, to fcarify it, and promote a more fpeedy and plentiful Suppuration. Mr. Petit affirms that the Callofity may be cut, by drawing it with an Inftrument. Operations of SVRGE RY. 26 firument. In the next place, the Surgeon cuts the Bridlings he meets with, putting his Finger into the Wound, and ufes Sciffars blunt at both Ends, for fear of pricking it. In order to cut thofe Bridlings, the Operator muff not look for thcm towards the Inteflin; for the Inteftin having many Folds and Wrinkles, there would be no cutting them. He muft thercfore look for, and cut them towards the Tuberofity of the Ifchion. If he opens fome VeffeI accidentally, he muft make a Ligature, if he can, taking care not to draw the Veffel towards him felf; for he would cut it: Or clfe he fhall ufe the Stiptick and the Compreffion. IF the Surgeon does not make a new Hole in the Inteftin with the Stilet, and conveys that Infirument into the Hole occafioned by the Difeafe, he muft cut the Inteffin upon his Finger one or two Lines above the FiZula, to remove all the Callofity. BEFORE the Surgeon makes an end of thofe Operations, he muft always remember to make the Entrance of the Fiffula larger than the Bottom: According to that Principle, he fhall cut all the Fat imbibed with the corrofive Salts of the Fi/lula; and the Difcafe will be more fpeedily and more fafely cured. To drefs a Fiflula in Ano, where 'tis neceffary to comprets fome opened Veffel, the Surgeon lays upon the Opening of the Veffel a fmall Dozel dipt in the Stiptick, and afterwards fqueezed. Then, he puts very far into the Anus a large Tent very long, and very large, efpecially at its Head, and tied in that place; fo that it may reach much further than the Bottom of the FiJ/ula, I mean, get into the Intefin beyond the Fif/ulk; becaife, when it does not reach farther than the Bottom of the Filula, it preffes there that Part of the Itcfithn which is opened, and a Furl S3 is SA rTreat fe of the is there formed, which remains always callous, and pccafions new iFTiulas. Mr. A*naud teaches us that Theory, which is grounded upon his Pradtice, and tells us, the Tent ought to be narrow at the end, that it muft reach beyond the Fiflula, and grow much larger towards its Head, the better to comprefs the Circumference, and to keep the Orifice of the 1i/lula very much dilated. THE Tent being introduced into the Fifl/ua, with the Circumflances juff now mentioned, the Surgeon pufhes it over the fmall Dozel, that lies upon the opened Veffel, and he puts on the Side oppofite to the Opening of the Veffel, fome Dozels between the internal Surface of the.flulaa and the Tent, that he may drive the latter towards the affedted Part, make by that means a fironger Comprefion, and flop the Blood more eafily. He alfo puts fome Dozels in the whole Circumference of the Tent; and to make a gieater Compreflion, he may, as Mr. Petit fays, withdraw a little the Thread of the Tent, and confequently the Tent it felf; whereby the Dozels will be ftill more compreffed. HE fills up the Interval of the Buttocks with narrow and graduated Compreffes, and fupports the Whole with the fame Bandage, which I have defcribed for an Abfcefs in the Anus, bidding a Servant lay his Hand upon it for fome time, by reafon of the Hemorrhage. SINCE the Defign of a Surgeon is to prevent the too fpccdy Growth of the Flefh, and to leffen the Botto n of that Wound before the Entrance, it follovws thlt in all the Dreffings, he ought to fill it well with TcUts; and confider, efpecially the ten or twelve firdt Days, whether he perceives any Sinuus untouchcd, offormed fince the Operation: This he, will know firk Operations of S u R G RY. I23 firft by the Sight, and fecondly by the Pus, which will have the fame Confiftence and Colour, without any Diminution of its Quantity. On the contrary, if the Pus grows white from the good Confiftcncy of it, if it has no ill Smell, and is in lefs Quantity, it will be a good Sign. LASTLY, when the Flefh grows on all Sides, and it appears from the fmall Quantity of Matter that the Wound wants to be cicatrized, the Surgeon introduces into the Amis a Lint-Tent fuitable to the Bignefs of the Anus, and a Finger long. He covers it with Pompholix, which is a good Drier; and when he perceives all along the Tent a Rivulet, as it were, formed by the running of the Matter, it is a Sign of a fpccdy Cure. C HA P. XXVII. Of the Wounds and AJfceffes of the Breaf? in relation to the Empyema. H AVING difcourfed of the Difeafts incident to the feveral Parts of the Abdomen, and defcribed with all poflile Accuracy the Operations proper for them; to follow the Order, that is obferved in anatomical Demonftrations, I muft proceed to the Difeafes of the Breaft, which require a chirurgical -Operation. And without lofing any Time about the Etymology of the Word Empyema, I fhall fay that we mean by that Word an Opening made between the Ribs, to let out the Blood, the Pus, or the Water diffufed in the Breaft.. THEr Bood ~at not be difufed into the.Breafl, but S 4 by, 164 A Treatife of the by the opening of fome of its Veffels which is generally occafioned by a Wound's penetrating into that Cavity. THE Wounds of the Breaft, as well as thofe of the Abdomen, are either fimple or complex. SIMPLE Wounds are thofe that are attended with no Accident, and require only a fpeedy Re-union for their Cure. On the contrary, Wounds are faid to be complicated, when they are attended with many Accidents. Among the latter, thofe that penetrate into the Breaft, and open tome Veflels, require a very particular Care, and a great deal of Skill in the Sur" geon, fince they cannot be cured without a Counter-Opening, which we call the Operation of the Empyema. IT is frequently very difficult to know whether the Wounds of the Breaft be penetrating, or not; and that Difficulty makes thofe Wounds more dangerous in procefs of Time, becaufe Surgeons are too curious to find out whether they penetrate into the Breaft, or not. That great Exatnefs is moft times the Caufe of the great Complication of the Wounds of the Breaft, tho' they were very fimple before. SOM E T I MES Wounds appear to be very fimple, and even to pierce only the Teguments, tho' they are very much complicated, and tho' they penetrate into the Capacity, and even open confiderable Veffels. I fupppofi, for inftance, that a Man has been wounded with a cutting Infirument, which has penetrated into his Breaft, and that he held up his Arm at that Time. If in fuch a Pofture, the Infirument had pierced the pedoral Mutcle, and got into the Breaft, when the Patient puts his Arm in a natural Situation, the peaoral Mufcle faftened to the Humerus, which followed it when ftretched, would be obliged to defcend alfo, Operations of SURGERY. 26f alfo, and its Fibers would hide the Opening of the Breaft in fuch a Manner, that the Surgeon would only find a fimple Opening in the Teguments, and cure it as a fimple Wound, though it would be very much complicated. Wherefore, in order to probe and examine that Sort of Wounds, the Patient muff be put in the fame Situation as when he was wounded. T HE Patient being placed conveniently, that the Surgeon may find out where the Wound lies, the Probe or the Finger will remove all Doubts, and difcover to us whether it be penetrating, or not. Befides, if the Wound penetrates into the Breaft, and the Paffage of the internal Air is a little conftrained, there will be an Emphyfema in the Circumference of the Wound, which will grow the more confiderible, as the Air continues to come out, and to infinuate itfelf into the Intervals of the Mufcles, and the fat Cells. IF the fnftrument paffed from one Side to the other, and cut the Pleura and the intercoftal Mufcles, the Patient is almoft ftifled, and feels a great Pain in that Place: There is an Emphyfema, diftinguifhed from the Oedema by a kind of cracking Noife, when 'tis touched: The Impreflion of the Finger does not remain as in the Oedema; and. the Skin does not change its Colour the firft Days; or if it be altered, 'tis only in time, and it grows blackifh by reafon of the Blood that is diffufed; and in the Oedema, it continues to be fhining and bent. THE frothy Blood, that comes out through the Wound, and the Air attended with a fmall Noife and Whiftling, are alfo certain Signs that the Wound penetrates into the Stomach, and that fome of its Parts are affeted. WHEN ,266,4 Treatsfe of the W H EN the Surgeon knows, without tormenting the Patient too much, whether the Wound penetrates, and when he perceives no dangerous Accidents, he mult go about to cure it as a finmple Wound, drefs it gently and carefully, and prevent the Air, as much as poflible, from getting into the Breaft. He is to blood the Patient, and nourifh him only with Broth the firft Days; and if there be no Effufion, the Patient will be cured by that Method. ALL good Praafitioncrs are agreed that the Complication of the Wounds of the Brcaft proceeds from the opening of large Veflels, the two great ExaCtnefs of the Surgeon, and his wrong Way of drefling. THERE- is a twofold Effufion of Blood: The one proceeds from the external Veffels, and the other from thie internal. THE Effufion of Blood upon the Diaphragm is attended with a very great Difficulty of breathing: The Patient fecls a very painful Heavinefs upon the Diaphragm, efpecially about the falfe Ribs.; and if he be fitting, the Situation of the Body being then perpendicular, all the Blood runs into the Diaphragm; which hinders its Motion, and confcquently encreafes the Difficulty of breathing. IF he lies on the Side oppofite to the Wound, he will feel a Pain and a Drawing all along the Middle of the Breaft: He will be very uneafy, and hardly iAble to breath. Thefe Symptoms will be the Con' fequence of a Liquid, which compreffes the Mediastinuma very much. Laffly, the Side of the Wound will be inflamed and diftended, and the Patient will frequently fall into a Swoon. IF. the Lungs 1hould adhere to the RPleura, (which may be known by the Probe and the Finger) and- if The Effufion was in the Lungs, and its Cells were full of Operations of SURG ERY. 267 of Blood, the Difficulty of breathing would not be fo great as in the E ffufion upon the Diaphragm but the Patient would now and then feel Suffocations, efpecially when he ftirred, and if the Wound of the Teguments was parallel to that of the Lungs, the Blood would ealily come out of it, and the Patient would fpit a little Blood; but if the Blood fliould come out with Difficulty thro' the Wound, the Patient would fpit Blood every Moment. T H E Prognofickof the Wounds the hods o e Breaff is more or lets dangerous, as they are more or lefs complicated. IF the Effufion be confiderable, and require frequent Dreflings, 'tis a very bad Sign; for it appears from thence, that the opened Vcflecls are large, and if the Patient is eafed for a Moment, when lhe is dreffed, becaufe the Breaft is emptied by every Dreffng, it may be faid that he lofes a great deal of his Strength by it, and will die upon that Account. ON the contrary, it little Blood comes out of the Wound, and the Effufion does not require frequent Dreflings, one may very well hope for a Cure. THE Danger depends alto upon the Situation of the Wound. For Inflance, the Wounds of the upper Part are more dangerous than thofe of the lower; becaufe all the large Veffels are in that Place, and the Inftrument cannot penetrate into it, without opening fome, and Death prefently enfues. The Wotmds of the hinder Part, for the fame Reafon, are not lefs dangerous. WHEN the Wounds of the Breaft are attended with a great Pain, a Fever, and an Inflammation, 'tis a bad Sign. THE Wounds of the Breaft made with Fire-Arms, arc very dangerous, when they affca fonim large Vefells. LASTLY, 268 ATreatif of the LASTLY, thofe Wounds, wherein there is an Adherence, are more eafily cured than others, provided no large Veflel be opened. IF the Wound of the Breaft with an Effufion upon the Diaphragm lies in a Place, that may facilitate the coming out of the Blood, the Surgeon muff only obferve whether the Wound is large enough to let out the diffufed Liquid. If it be too narrow, as a Wound occafioned by a Thruft with a Sword, he muff dilate it by putting into it a grooved Probe, and conveying it near the intercoftal Mufcles, and above the Groove he muff cut with a ftrait or crooked Biftouri, &c. Afterwards, he places the Patient in fuch a Situation, that the diffufed Blood may be difcharged into the Wound, and come out eafily; and whilft the Patient is thus fituated, the Surgeon bids him flop his Nofe, and keep in his Breath, that the Lungs being full of Air, may drive the Blood through the Wound. INJECTIONS are alfo ufed; but they ought to be very gentle, for fear of occailoning a Cough, which would trouble the Patient. Thofe Injedions muff alfo be warm and the Surgeon muft keep the Room ihut, corref the Air with Fire, and then proceed to the Dreffing, as I am going to fhew, fpeaking of the Operation of the Empyema. IF the Wound lies in the upper Part of the Breaft, and it appears by all the Signs abovementioned that there is an Effufion of Blood upon the Diaphragm, it muft be let out by a Counter-opening, as I fhall fay, after I have explained the Signs of an Effufion of the Pus in the Breaft. MR. Verduc defcribes thofe Signs fo well in his Operations, that I fhall fet down here what he fays upon that Subjed. Operatons of S RG E R Y. 269 S W E know, /ays he, that an Abfcefs is forming " in the Lungs or in the Pleura, when the Peripneu"mony or the Pleurefy are not cured by the ufual " Remedies, and when thofe Difeafes have lafted a" bove fourteen Days without any Sign of a Dif" charge by fpitting, fweating, Stools or Urine for " it muff be expe1ed that the Abfcefs will be formed "within the twenty-fifth, or thirtieth Day of the "Difeafe, fooner or later, according to the Strength, " Age, and Conftitution of the Patient, the Violence " of the Difeafe, and the Time of the Year. " WE know that the Abfcefs is formed, when "without any of thofe ufual Evacuations juft now "mentioned, the Fever, the Pain, and the other Ac" cidents abate, and difappear for a time, and the Pa"tient finds himfelf eafed, and lefs oppreffed. But " if foon after, the Pain and the Oppreflion return Stho' in a lefs Degree; or if the Fever returns, Sencrcafes, and is frequently attended with irregular SShiverings, with a Cough; or if the Patient fweats, "efpecially in the Night; or laftly, if the Pain grows Sheavy and grievous, all thofe Symptoms denote an "Abfcefs. "c WE know that 'tis an Abfcefs between the two "Folds of the Pleura, when the foregoing Symptoms Shave been violent, for Inflance, when the Fever has Sbeen very fharp, the Pains very finarting, and the "Cough very dry without fpitting any thing; which Sat the fame time makes the Refpiration painful; and " if the Lungs fuffer, the Fever before the Abfcefs is c not fo great, the Pain is duller, and the Oppreflion "greater, though the Refpiration be lefs painful, and " the Cough more violent and more frequent: The SPatient fpits Blood, or Pus, &c. very often: He is Sill-humourcd, when he coughs and fpits. We Sknow 1 I: 7A 7reatfe of the " know, the Abfcefs to be in the Cavity of the Breaft, "when the Patient feels a painful Heavinefs upon the " Diaphragm, efpecially about the falfe Ribs, and did "'not complain of it before: When he fpits, and "feels-that the Heavinefs of the Diaphragm, and "confequently the Difficulty of breathing encreafcs. "If the Patient lies on that Side, in which he al"ways felt a Pain, he will find himfelf eafed; but if " he lies on that Side, which was not affefted, the " Matter we fuppofe to float in one of the Sides " of the Breaft, will lie upon the Mediaftinum, and "occafion there violent Pains, and a great Difficulty *"of breathing. "IF the Effufion be on both Sides, the Patient " cannot lie upon any Side, but the Accidents juft Snow mentioned will happen. The moft conveni< ent Situation for thofe Patients is to lie down up"on their Backs: They cannot fit without feeling a " Pain and Heavinefs upon the whole Diaphragm, and 4 they are ftifled in that Pofture, being hardly able ""to breath, unlefs the diffufed Matter be very in0f confiderable. "THE Signs of an Effufton qf Water in one, or " in both Sides of the Breaft, are altogether the fame "as thofe of an Effufion of Blood: They are only " diftinguifhed by the foregoing Symptoms: If the, Dropfy, for Initance, was only preceded by a flow "Fever, 'tis then but feldom that there is any Wa"ter in the Breaft without a Fever, or fome other "long Difeafe; whereas the Abfcefs was preceded by ' an acute Fever with a Pain in fome Part of the Breaft, "Befides, the Dropfy of the Breaft is attended with "Thirit, and a dry Cough; the Face is pale, and "fornetimes bloated, the Legs and Feet fwieli a little; "dthe Patient has a flow Fever, and when he firs ve Operations of S GER Y.R 2771 ' ry much, or all of d fudden, he hears fometimes a " Fludtuation in the Breaft, much in the fame Man"ner as when a Bottle half full of Water is ftirredY CHA P. XXVIII. Of the Operation of the Empyema. B EFORE the Surgeon begins that Operation, it is not improper to know whether it be ufec ful, or needlefs. For Inftance, if the Wound lay in the lower Part of the Breaft, and gave a free Paffage to the diffufed Blood, it would be needlefs to perform the Operation, fince the only Defign of the Sur* geon is to let out the Blood, or the purulent Matter, IF the Wound was in the upper Part of the Breaft, and fome large Vcffel was opened, affording a great deal of Blood, as may be known by the Blood, that comes out of the Wound almoft continually, without any Eafe to the Patient, in fuch a Cafe the Empyema would be ufelcfs. IF the Effufion of Blood or Pus was only in the Lungs, which may be known by the Signs abovementioned, 'tis plain the Opening of the Breaft would be of no Ufc to that Difeafe, unlefs the Abfcefs was fuperficial, and the Lungs adhered to the Pleura. THE Surgeon being well informed of the Confequences of the Difeafe, both from his own Knowledge, and that of others, ought to let out the Blood, or Pus, which we fuppofe to be diffufed upon the Diaphragm. In order to it, he muft open the Breaft in a Place from whence the Fluid may be difchargcd, and cafily come outt The moft convenient Place is... * * - *' " "...........th e 27Z.4A Tieatife of the the hinder and lower Part of theBreaff, between the, third and fourth falfe Ribs, reckoning from the lower Parts up to the, fuperior, at the Diflance of five or fix Inches from the Spine. THE Operator muff not open the Breaft nearer the Spine, becaufe before he could come to the Ribs, he would find many Tendons of the Mufcles of the Spine, efpecially the Tendons of the Sacrolumbarius, which adhere to the Angle of each Rib; and the Cutting of thofe Tendons would be very painful, to fay nothing of the Trouble they would give to the Operator. BESIDES, if he fhould open the Breaft fo near the Spine, he would infallibly cut the intercoftal Veffels, which are not yet in the Sulcus of the Rib, fince it begins to appear only at its Angle. Lalfly, the fmall Interval between the Ribs, from their Angle to the Spine, does not allow the Operator to openr the Breafft there, fince that Operation would not be attended with good Succefs. It may therefore be performed at five Inches Diftance from the Spine, but the Breafft ought not to be opened much farther, for fear of hurting the Diaphragm. IF the Patient be lean, the Surgeon cannot be miftaken in telling the Ribs, provided the Patient be made to lean back, in prder to relax the Mufcle called the great Dorfal i Buit if the Patient be fat, or the Emphy~fma very confiderable, good Praatitioners advif us to bend the fore-A-rm of the Patient, to put his Hand near the Xiphoid Cartilage, and in that Situatiofi'to look for the lower Angle of the Shoulderblade: When the Surgeon has found it, he takes its M hafure four Inches under that Angle, and at five or ~ixi hes Diftace from the Spine, as'I have faid; and then jfe will be in the true Place where the Operation toughtto be performed. AFTER Operations of SUR G R Y. 273 AFTERWARDS, according to Mr. Arnaud's Prefcrip tion, he pinches in that Place the Skin, the Fat, and the dorfal Mufcle all at once, in order to perform the Operation more fpcedily, and preferve the Patient from Pain. THE Surgeon bids a Servant do the fame, (fuppofing thePatient to be ftill reclining back) and then cuts with a ftrait Biflouri all the Parts juft now mentioned, by an Incifion about three or four Inches long. IF the Patient was very fat, or if there was a confiderable Emphyfema in the Teguments, the Surgeon could not cut the great Dorfal with the Skin: He muff therefore in fuch a Cafe be contented to cut the Skin and the Fat; and then he fhall cuf the great Dorfal, and dilate the Wound to difcover the Ribs, and tell them cafily, in order to open the Breaft in their Interval. THE Surgeon, to cut the intercoftal Mufcles, muff place the Patient in a different Situation: Whereas he was before ftretched, to relax the great Dorfal, he muff now bend forwards, to keep the Ribs afunder in their hinder Part, and confequently to bend the intercoftal Mufcles. THE Patient being in that Situation, the Surgeon takes with his right Hand a crooked Bftouri: He conveys the fore-Finger all along the Back of that Inftrument, and conceals the Point of it with the End of his Finger: He pierces the Mufcles, which being difC.tended, as I fuppofe them to be, are eaftly cut: And ýas foon as he perceives that he is in the Cavity, he cuts the intercoftal Mufcles tranfverfly; their Setion, which Way foever it be made, is not confiderable enough to require from the Operator that he.fhould too much follow the Dire6tion of their Fibers.~ He muft make a great Opening there, without faring to **~~; T~ ,274 A 7'1eatf/e of the touch the Lungs; for Mr. Petit affirms that as foon as, the Air aCts upon them, they fink, and remove from the Inftrument. However, the Surgeon ought to ufe all the neccffary Precautions to avoid hurting the Lungs. WHENi4 he has made thofe Openings, he muft obferve whether the great Dorfal makes any Bridlings, and cut them. Nay, he muft make fome Angles in the great Dorfal, by makingc a tranfverf& Incifion; which enlarges the Outfide of the Wound. AAFTERWARDS, the Surgeon puts his Finger into the Opening, lihe gently takes off the Ad'herences of the Lungs with the Ileura, if there are any: He bends the Patient ori the Side of the Wound, to let out the Blood, or Pus; and when the Lungs appear at the opening of the Wound, he muff pufh them back a little withl a female Catheter. He muft make fome warm Injehions into the Wound, and pump them immediately. Thofe of Perficaria are excellent; and when there is an Empyema by Effufon, the Injeaions of Marfh-mallows are preferable, if the Patient be troubled with a Cough. To drefs the Wounds, all Authors advife to put into the Opening a large Lint-Tent, firm and well tied, that it may be the better adapted to the Interval of the Ribs; and they fay, it ought to be crookcd. at the End, for fear it fhould hurt the Lungs. Lafily, they pretend that this Tent will prevent the Re-union of the Wound; which would be too foon clofed up, without fuch a Caution. I have' ffiifciently dwelt upon thofe Accidents, that follow the Ufe of a Tent, efpecially when I difcourled of the Gaforrhaphy; and I am ftill more unwilling to approve of it in the Breaft than in the Abdomren, no more than the Cannulas of Lead, MR. Operations of S U R G E R Y. 27 MR. Petit dreffes the Empyema, after the Operation which I have juft now defcribed, by putting into the Wound a Piece of Linnen, cut in fuch a Manner that it may have a kind of a Tail. That Piece of Linnen is fufficient to prevent the Re-union of the intcrcoftal Mufcles, and at the fame time does not hinder the Matter from coming out continually thro' the Wound. Afterwards, he puts in a tied Dozel, and above it three or four more, and fome Plagets. IT being neceflary to keep the Air, as much as poffible, from getting into thofe Wounds, the Surgeon lays upon that whole Apparatus a large Plaiffer of Andreas a Cruce, which ought to be fpread thick -in its Circumference. THE Opening muff be clofed up, when no more Matter comes out of it; and the upper Wounds of the Breaft ought to be clofed up as foon as poffible. T H E Bandage is a Napkin folded into three, according to its Length, and applied about the Breaft, and fupported by the Scapulary, as I have defcribed it, fpeaking of the Wounds of the Abdomen, THE Abiceffcs by Effufion, which attend, as I have faid, a Peripncumony and a Pleurefy, being fome-. times contained in a Membrane, which ferves as a Bag like the two Folds of the Pleura, or in the external Membrane of the Lungs, and being fometimes diffufcd upon the Diaphragm, by the Rupture which Sthe Salts of the Pus have occafioned in the Eag, require indeed the Operation of the Empyema, but in different Places, according to the Difference of the Difeafe. WITH refpea to the different Places, where thofe Abfceffes lie, we prefcribe, in order to make the Operation, a Place of Choice, and a Place of Neceffity. The firft is only proper for Abfccffes diffufcd upT z on 276 A T"eat;/e of the on the Diaphragm, and is the fame with that above prefcribed for diffufed Blood. BUT the Place of Neceflity being known to us by the Nature of the Difeafe, we fhall perform that Operation wherever we find an external Tumor, in which we feel the Flu6uation of a Liquid; for thofe Abfceffes corrode the external Membrane of the Pleura, the intercofftal Mufcles, &rc. get in between two Ribs, and occafion a Tumor outwardly, which opens fome.times of itfelf. I have feen two Inftances of it. The firft in a Grey Friar of VitrO, about feventy-fix Years of Age. My Father enlarged the Opening, by putting into the Abfcefs a grooved Probe, and cutting upon its Groove the Skin and intercoflal Mufcles with a Razor, as he ufed to do. I dreffed the Patient about fix Weeks always with a large Tent, as my Father prefcribed. Afterwards, a Cannula was put into it; and the Patient remained with a fiflula. TH E fecond Perfon, in whom I faw that Difeafe, was a priviledged Surgeon of the fame Town. He came to Pariz, where he was immediately taken with a Peripneumony. The Inflammation was fo great, that it took up the whole Side, with a confiderable Tenfion. He was carried to the Hotel-dieu the fifth Day of his Difeafe, and blooded eleven times in three Days by the Prefcription of the Phyficians of that Hofpital. Notwithftanding the great Care that was taken of that Patient, an Abfcefs was formed in the Lungs, which appeared about the fortieth Day of his Difeafe, by a Tumor between the fixth and feventh true Rib, on the left Side. Mr. Mery ordered a Poultice to be applied to it: The Abfcefs broke out the very next Day, and the Patient died. WHEN the Surgeon knows by the Signs abovementioncd that there are Waters in the Breaff, and- when all Operations of SURGER Y. 277 all the Remedies proper for their Evacuation by other Paflages prefcribcd by wife and prudent Phyficians, prove ineffeaual; the Surgeon muft look for the Place of Choice already affigned, and thruft into it the grooved Trois-quarts of Mr. Petit; and if the Waters are clear, this will be fufficient for the Cure: 'But if there are Strings, or if the Waters appear muddy, the Surgeon muff open the Interval of the Ribs, and make Injeaions into the Breaft. T H E Drefling of thofe Operations Confifts in laying a good Comprefs dipt in Brandy upon the Opening, and the circular Napkin with the Scapulary, as ufually. To perfed the Cure of thofe Patients, upon whom the Operation of the Emp)yema has been performed, they muft be blooded in the Arm, efpecially if the, Operation was performed in confequence of diffufedc Blood: Afterwards, they are lid down upon6 their Back, the Head being a little raild, that tl luids may eafily run ct4c THE Patients are epd, when there is a Neceffity for it, I mean, when they find themfelves opprefled, have much ado to breath, and feel the Weight of the Fluids upon the Diaphragm, as before the Operation; fo that according as thofe Accidents happen more or lefs freqntly, the Drflings muff be more or lefs repeated;for they cannot be fixed to, a certain time, as in the Wounds of the other Parts. THE Surgeon takes Care, at every Drefling, to make InjeCtions, as I have prefcribed, and to pufhl back the Lungs with a large Probe when they appear at the Wound, and, hinder the Blood or Pus from coming out. Dur Time, the Windows ought to be fhut up, Air purified with a Fire in the Chimney, and Chafing-diflles laid even T 3 upon 278 A Treatife of the upon the Bed. The Surgeon keeps his Apparatus ready: His Injetions muff be warm, that he may drefs the Wound as foon as poflible, and not keep it too long expofed to the Air. During the Courfe of the Difeafe, gentle Purges and proper Gliflers ought to be prefcribed. The Patient muft live upon good Broth, and Jelly, and in time upon Eggs; and his Food will be encreafed by degrees, when the Danger is ovcr. C H- A P. XXIX. Of incy/l7ed 7Ynmors, known by the Names of Jfcens, Glan S i, Scizrrhus's, Cancers, and of thofe callekd biy the Aickents Atheroma, Steatoma, and Mceliceris. IF I was willing to enlarge upon the different Opinions of Authors about the Nature of incyfted Tumors, and fhould undertake to treat of thofe Difeafes according to their Principles, I fhould perhaps be more prolix upon that Subjet than they themfelves are. I fhall therefore confine my feif to what I have learned of the illufirious Mr. Petit, both in the Cures which I have feen him perform, and in two Difcourfes delivered by him, one at the Royal Academy of Sciences, and the other in the Amphitheater of the Mailers Surgeons of Paris. WVITHOUT minding the Order, that is commonly obfcrvcd in the Explication of thofe Tumors, he follows a Method, whereby he is able to remove more Weffeually the Prejudices of the Vulgar. OperCIif;s O/ S U R G E R YO 279 ALL incyffed Tumors, fays he, begin with the Dif. tention of a Gland, which alhmecs different Farms, according to its different Degrees of Growth, &c. Hence it is that fome are flefhy, others from Definxion, degenerate into Cancers; moft of them have Bags,. and fome have none at all. Some of "em, fippurate; and the Pits contain'd in them iS of a diff'em^.nt Kind, vhermby they are diftinguifhed, as 1 fhall {hew by-and--by. SINCE alilTumors proceed only at firft from the Diftention of one or many Glands, by 'reafon oftht nutritious Juice, and the Lyunpha thickcn'd by their own ill quality, or by the bad Difpofition of the Gland it ficf; it is certain, that fuch a Thickening will obfitru& the Velfcls in the Intide of the Gland, and the-, Courfe of the Liquids contained in them. THosE SLiquids being (lopped and thickened in their Vefels, the latter wil be dilated, and take up more Room; by which means the whole Gland muft needs fwell, and the Membrane that inclofes it,; wYill be farther removed, and confequently more diffended. THE Membrane of the Gland, being removed beyond its ufual Bounds, and diftended, xvill comprefs the Veffels, that run through its SubflanIce to convey or bring back the Ly;np/a or the Blood. But among all thofe Xeffhls, the Veins and Arteries wilt be lei' compreffed than the lymphatick Veffiels; becaufe the Blood moVes faltcr than the Lynipha, and becaufe thC Blood-Veffels have an Elafticity, which the Lymphatick have not. THE Lyrphatick being therefore more eompreffed, the Lympha will be accumulatcd in the CircumfPerence of the Gland; which will produce in it a Kind of Oc.. dema. But the Lv-Ypha being at refi, and unable to c-ntinue its Courk-C, Iby rcafon of the Comprdfion in T + lthle 2i80 1A Treattfe of the the lymphatick Veffels, it will ouze thro' the Pores of their Membranes, and fufficiently moiften and relax the Membrane of the Gland, to facilitate the coming in of the arterial Blood and nutritive Juice, which not returning in the fame Quantity, nor with the lame Facility thro' the Veins and lymphatick Veffels, by reafon of the Obftrufion which we have fuppofed in the Infide of the Gland, thofe two Liquors will afford a new Matter to the Bulk of the Gland. Such is Mr. Petit's Opinion concerning the Growth of incyfted Tumors, which will be quicker or flower, according as Oedemas are formed more or lefs frequently upon the Membrane of the Gland, which relaxing it more or lefs, will allow it to extend it felf, and to yield to the continual Influx of the Juices, which thicken in the Gland by mixing with thofe that are already grown thick. B T if the Membrane of the Tumor happens at laft to be fo relaxed as to allow the Blood and Lympha to come eafily into the Gland, thofe Liquors will come into it in great Quantity. But being flopped by the Obftrufion, which has occafioned the glandulous Tumors, as I have juft now explained it, they will gather in greater Quantity, and dilate their Veflels, from the Membrane of the Gland to the Place of Obftrution. ALL thofe Veffels being dilated, 'tis plain the Tumor will very much increafe, its V efels will grow wider in Proportion, even the fmalleft of them, and by an exceflive Extenfion and Dilatation, their Coats will grow fo thin, that being no longer able to refift the new Influx of the Liquor, they will open, and let out the Liquid contained in them 5 which will make confiderable Differences in the Tumor, according to the different Effufipn that happens in it, If the Effufion proceeds Operations of SUR GERY. 81 proceeds from the Rupture of a lymphatick Veffel, the Lympha coming out of the broken Veffel, will form an Hydatides or watery Tumor. If a Vein, through an exceflive Dilatation, opens and occafions an Effufion of Blood, it will be a bloody Tumor, which we call varicous. On the contrary, if the arterial Blood be diffufed, it will be an aneurifmalTumor. IF the Blood-Veffels and the Lymphatick are broken in different Parts of the Tumor, thofe Effufions will be a confiderable time without making any Alteration; but if the Blood and Lympha mix together, they will produce different Alterations in the Tumor, and quicker or flower, according as their Mixture is more or lefs equal. For if thofe two Liquors mix together in a proportioned Quantity, there will arife a Fermentation, which will very much increafe the Tumor, and be attended with a Rednefs, and a confiderable Heat. IF the Tumor does very much increafe, all the fmall nervous Fibers, which convey the animal Spirits into it, muff needs be very much diftended, and very fufceptible of a Tremor; and being over-much agitated by the Fermentation in the Tumor, they will drive back the Spirits towards the Brain, and occafton a very great Pain. IF a great Pain occafions a great Agitation in the Liquids, the Blood and Spirits will be in a violent Motion. And becaufe a Fever fuppofes a violent Agitation in the Mafs of Blood, the Tumor (fuch as we fuppofe it) will be attended with a Fever. LASTLY, Part of the different Liquids, that are in the Tumor, cannot be in a Fermentation, but their Principles muft be difunited, and change their Nature, which will produce Pits. But if the Liquors diffufed in the Tumor are not in a proportioned Quantity, SA Treatife of the tity, all thofe Accidents will appear but flowly. For Inftance, if a great deal of Blood, and a fmall Quantity of Lympha be diffufed, the Tumor will always be fanguin, the Fermentation will be flow, the Pus will not be formed till a long time after, and perhaps not at all, if there be no Lynpha; which is plainly demonfirated by the Varices and Aneurifms. On the contrary, if the Lympha prevails over the Blood, the Tumor will always be ferous: There are in it commonly fome Clods of Blood; and there is one chiefly at the opening of the Veffels, which ftops it, and prevents its Effufion: And becaufe the Lympha is a Li, quor, that has very little Motion, the Fermentation will flill be flower than in the fanguin Tumors; as it plainly appears from 'Dr;fes of all Kinds, which laft a confiderable time without producing 'Pus. SINCE we are agreed that an exaft Mixture of the two Liquors ferments after a certain manner, and forms u's, we muft alfo acknowledge, that an unequal Mixture of thofe Liquors will ferment differently, and that from thofe different Fermentations there will arife many Differences in the Nature of the Pus. Thus it appears, that in the fame Tumor, there may be fome Parts which have not wholly loft the glandulous Texture. Others will be callous, by reaIon of the different Degree of Fermentation, of the irregular Salts with which they are imbibed. In other Parts, there being no Effufion but of the Lympha, it will be ferous. In others, the Blood being the only diffufed Liquor, there will be Clods of Blood. Laftly, the Blood and the Lympha being mixed together in fome Parts of the Tumor, there will arife Pus, which will be different, according to the Difpoiition of the Liquors, the Unequality of the Salts, and the different Degree of Fermentation. So that we find fome Operations of S v R G E R Y. I fometimes in certain Parts of thofe Tumors as laudable Pus, as in the kindly Abfceffes whole Matter is thick and curdled, and fometimes 'Pus like Tallow, thick Milk, or Honey 3 whereby the three Sorts of Tumors, called by Authors Atheroma, Steatoma, and AMelicerit, have been diftinguiflhed. Mr. Petit has extirpated fome incyfted Tumors, wherein he found all thofe different Matters, of which he has drawn Models in Wax, which he has fhcwed in publick. I have enlarged upon the Membrane of the Gland, and fufficiently explained how it yields to the Diftention of the Gland; fo that one may very well believe that it forms the Bag of thofe Tumors. Now becaufe that Membrane may have a clofer Texture in one Place than in another; or becaufe the Lympha relaxes it more in fome Parts than in others; one may very well forefee that the Membrane will be able to refit the Diftention of the Gland, in fome Part of its Circumference, and that in others it will yield and cafily firetch: Which is the Reafon why thofe Tumors have very different Figures, fome being flat, and others round; laftly, fome are oblong, and others have all Sorts of irregular Figures. SOME Tumors, though very hard, have no Bags; which feems to be a Paradox, after what I have faid of Tumors and their Bags; but that Difficulty may be removed in the following Manner. IF it be true, that all Tumors begin with a glandulous Tumor, it is no lefs true that all Glands have a Membrane, and confequently that, all Tumors muft have a Bag, or a Tegument. And if there are Tumors without, it is not becaufe the Gland, which has occafion'd the Tumor, had no Membrane; but becaufc the Membrane of that Gland burited in the very 284 A Treat;/e of the very Beginning of its Dilatation; or, according to others, becaufe the twifting of the fmall Veffels, which compofe the Body of the Gland, diftending it felf, and increafing more and more, thofe Veffels are forced to remove on all Sides, and to revolve in Folds upon one another by which Means, what was internal will become external, and by that Inverfion the Membrane of the Gland will be contained in the Infide of the Tumor. This has been frequently confirmed by the Extirpation of thofe Sorts of Wens, in which nothing appeared next to the Skin but a flefhy Mafs 3 and when they were diffeecd, they found in their Centre a membranous Body, more or lefs hard, and of different Figures, according to the different Growth of the Gland. Mr. Petit has feen fome of thefe Tumors, wherein one Half of the Membrane was without, and the other Half within. Secondly, Some Membranes, by much ftretching as the Gland increafes, grow fo thin, that they wear out at laft; which is the Reafon why fome Remains only of the Bag are to be feen, when the Tumor is extirpated. Thirdly, The Bag may alfo difappear; becaufe, by adhereing to the adjacent Parts, it is confounded with them. Mr. Petit has feen fome Tumors, the Bag whereof was adherent, and confounded with the Fat. Fourthly, The Coats of fome Tumors have been corroded by Putrefadion; and we cannot have a better Proof of it, than by recalling to mind certain glandulous Bodies, which after Diftention, have been impofthumated; and when they were opened, no Sign of a Bag, or but a very fmall Part of it, was found in them. B E S I D ES the Tumors, of which I have given an Account, we know by Experience, that there are Operations of SURGERY. 2 f are two other Sorts. Some are nothing but a Dilatation of the lymphatick Veffels, or of the Veins and Arteries; and each of them has a proper Name, according to its Kind, as I have explain'd. The fecond Sort of thofe Tumors is derived from the fat Cells; and thefe are produced by the oily Humour of the Blood, detained in the Cells of the fat Membrane, commonly call'd the Fat. Mr. Petit has known a Tumor of that Kind in a Woman; It weighed 48 Pounds, and lay between both Shoulders. THE Membranes of the Veflels in the firft Sort of Tumors, and the fat Cells in the other, form the Bag, and therefore we have reafon to fet down three Sorts of Tumors, viz. the glandulous, the vaJcular, and the veJicular. No T to omit any thing, that contributes to the Formation, Growth, and iad Confequences of Cancers, and other incyfted Tumors; I fhall here fet down my Thoughts concerning the fhankery Humour. AUTHORS are very much divided in their Explication of that Humour. Some afcribe it to a Defret in the Part, and the Reafon they alledge for it is, that when a fhankery Tumor happens to be extirpated in its Beginning, it is cured without any Relapfe. Others fay, the Blood is infeted with that Humour; and to maintain their Opinion, they obferve, that when a fhankery Tumor has been extirpated, the Mars of the Blood quickly produces another in other Parts. Laftly, others being willing to reconcile thefe two Opinions, fay that the fhankery Tumors are occafioned by the Defet of the Part, and the Infe&ion of the Blood. As for me, I have already faid, that all thofe Tumors have at firft no other Caufe but the Diftention of one or many Glands; becaufe the nutritious Juice, and i86 T re~at~fe of the and the Lmpbha are grown thick in it, either by their own ill Habit, or by the bad Difpofition of the Gland it felf. And Mr. Petit is fully perfuaded that the Defeft of the Part has the greateft Share in it, fince he has cut off fhankery Tumors, either opened or unopened, and even of all Kinds, from People affeaed with the King's Evil, the Scurvy, and the venereal Difeafe, and they were perfe&ly cured. How E v E R, I don't deny but the Blood contributes very much to thofe Tumors, as Mr. Petit believes; but it will not be infedcd by them before they have lafled long, and are come to fuch a Degree that the Surgeon has loft all Hopes; and then the Tumor having communicated a great many faline Particles to the Blood, it will be wholly impregnated with them: And yet it appears by feveral Inflances, that when the Nature of the Blood has been, as it were, changed by a good Courfe of Diet, and with the Help of Phyfick, Surgery overcame the Diftemper. ALL Tumors in general may grow fhankery by ill.Ufage, viz, by the Application of Remedies, that put the Salts of the Tumor into Motion, or coagulate the different Liquids contained in it, fuch as the Poultice of Crumbs of Bread, which, tho' anodyn, grows fowr, ferments, and coagulates the Humors, unlefs it be newly made, frequently renewed, and diluted with new Milk, that does not curdle, and provided the Bread be unleavened. 'Tis true, there are fome Tumors more fhankery than others: They do not rife equally; and one may fee in their Surface Prominencies of different Colours, and Veflels diffended, varicous and bloated; the Whole being attended with violent Pains. Hence it is that ibme have been of Opinion, that the Cancer was an Animal, which corroded, and, as it were plucked out Operations of S u R G ER Y. i37 out the Pap, miftaking varicous and diftcnded 'Vcfeels for the Fect of that Animal. Nay, their Folly went fo far, as to lay upon thofe opened Tumors rome Pie' ces of Flefh, to feed that pretended Animal; as if it were impoffible to give truer and more plaufible Rcafons of all thofe Symptoms. THERE arc fomc Tunmors very diffcrcnt from the latter, fince they arc formed, increafe, and ulcerate without any Pain. Certainly thefe Tumors oughl not to be looked upon as Cancers. BEFORE I put an end to there Explications, I mull refolve a great Queftion, viz. Whether incyfted Tumors, fuch as Wens, Schirrus's, Cancers, &c. have Roots and Adherences; for it has been laid down as a Principle, that when the Roots reach very far, and the Tumor is adherent, it ought not to be meddled with. 'Tis a vulgar Error to be found among all thofe, who have writ upon this Subjet, to fuppofe, in Tumors, whether they be flhankery or not, long and penetrating Roots, which prevent the Succcfs of the Operation. 'Tis certain there are no Roots; and Mr. Petit's Experience, and Obfervations upon a great many Tumors, even of all Kinds, which he has cut off, has taught him, that what has been miftaken for Roots by thofe, who did not carefully examine the Matter, are nothing but conglobated Glands, that have been compreffed by reafon of the Diftention of the large Tumor, which precfing their VcfTcls, forced the Liquors to flay longer in them. 'TIs alfo true, that one may fometimes perceive, by feeling all thofe Tumors, fome Adhcrcnccs, which feem to be very confiderable; but they ought not to be looked upon as Roots adhering to the adjacent Parts. Mr. Petit abfolutcly denies the Exiftence of Roots 28.Treatffe of the:Roots and Adherences; and when a Tumor is not imoveable, he explains it in the following manner, and thews in what Cafes it happens to be fo. SOME Tumors lie in certain Places, wherein at the very Beginning of their Growth, they were moveable and flu&uating; which happens to the Glands, that are diftended under the Arm-pits. But when they have attained to a certain Degree of Bignefs, they become unmoveable, not becaufc they have contraaed fome Adherences with the adjacent Parts; or becaufe they have fome Roots, which keep them in that Situation; but becaufe they take up the whole Cavity of the Arm-pit, and being compreffed on all Sides, they cannot ftir. AGAIN, the Tumors to be found under Aponeurofes, or under large Mufcles, fuch as the Aponeurofis of the Fafcia lata, under the great Dorfal and petoral Mufcles, &c. I fay, thofe Tumors are unmoveable, not by reafon of any Adherence, but becaufe being compreffed by thofe Parts, they cannot ftretch out according to all their Dimenfions, and are confequently without Motion. Mr. Petit has cut off a Tumor of that Kind: It feem'd to be adherent, becaufe it lay under the Mufcle called, the Serratus Anticus major, the latijfimu dorfi, and the pettorala e but in the Operation he perceived no Adherence: That Tumor weighed ten Pounds. LASTLY, fome Tumors are very flat, and of fo great an Extent, that they cannot move. It would be wrong to fay, they have Adherences. CHAP. Operations of SUR GER Y. CHA P. XXX. Of the Operation of the Cancer, and incyfled Tumors. S INCE we are now apprifed of the Nature of incyfled Tumors, and that they are all derived from a glandulous Tumor, or from the Dilatation of fome Veflels, as I have explained it, that Knowledge muft needs lead us to a quicker and fafer Method of curing them. ONE may try the Cure of incyfied Tumors in their Beginning, by the Application of external Remedies j and if one may with the Help of thofe Remedies foften the Gland, refolve the thickened Juices, and open a free Paffage to the Veffeis, the Tumor will grow lefs by degrees, and wholly difappear. T HE Glands of the Breaft, or of the other Parts, are fometimes diftended by Blows, and would frequently degenerate into Cancers, if not timely prevented. I have had fometimes fuch Tumors under my Care, and I cur'd 'em by uftng the two firft Days a Poultice of Crumbs of Bread, frequently tepeated, to abate the Tention and Inflammation. And to refolve the thick Juices in the Gland, I laid every Day upon the Tumor a Plaifler, taking care to purge the Patient frequently. Such is the Praaice of the Surgeons of the Hotel-Dieu; and it fucceeds very often. WH En the beft external Remedies have not fuc-- ceeded, the Surgeon muff proceed to the Operation, which will be different, according to the different TuV m ors. 290~ 4 Treat;ie of the mors. If the Tumor be lymphatick or watery, or if it be purulent, Mr. Petit advifes to open it, in its whole Length, to evacuate the Matter contained in it, and to examin well the Bag, with which it is covered; for if it be not vitiated, the Surgeon muft make it fuppurate in its internal Surface but if it be hard and callous, he muff cut as much of it as he can, and confume the remaining Part with Caufticks. Afterwards he muft reunite the Wound as foon as poffible. Mr Petit advifes to cut off all the other Tumors abovementioned, and even the fangnin, that is, the aneurifmal Tumors, which partake of the Aneurifme and the fimple Varix. But Caufticks ought not to be ufed to perform thefe Operations for befides their Slownefs in working, they frequently make the Part worfe than it was, and occafion a great Pain. To remove thofe Tumors, the Surgeon muff not open them lengthwifc, for fear of opening fome Blood-Veffels, which are dilated in the Subftance of the Gland, and occafion a periodical Hemorrhage, of which the Patient dies the third, fourth, fifth, or fixth Day. I N order tc know the periodical Time of thofe Hemorrhagies, anl the Difficulty of flopping them, the Surgeon muft remember what I have faid concerning the Growth of thofe Tumors, and the Compreffion of their Vefels, which preventing the Return of the Blood and Lym pha, makes them flay in the Veffels of the Gland; which cannot happen but thofe Veffcls muft be dilated, and their Dilatation will be in Proportion to the Bignefs of the Tumor. And therefore, if the Veffels within tle Tumor be opened, they will afford a great deal of Blood; becaufi they are very fidl of that Liquor; but the Arteries, which furnilh them with Blood, being very finall, will not fill OperationsI of SUR G ER I. 291 11 them up before a certain Time; which w'ill ddcafton a periodical Evacuation of Blood, that wilt be longer or fhorter, according to the Proportion between the internal and external Vtefels. On the contrary, if the Surgeon removes the Membrane of th6 Bag, and takes away that opened Tumor; together with its CyQflis as Mr. Petit ha. done, there will only appear fome finmallDrops of Blood, hardly perceptible; becaufe nothing remains but (imall capillary Veffiels; which will foon ceafe to flow when the dilated VeLfels of the Gland arc taken off. Mr. Arnaud explains that Ph/~nomenon by a very plain Comparifon. He fays, thofe Tumors may be compared with the Placenta in the Uterius. If the Placenta be torn, or half deftlroyed, it emits a gteat deal of Blood periodically. But if the Placenta be carefully removed, all the large dilated Veffels are Itemoved, ( for every body knows, the Placenta is nothing but a Complication of dilated Veflels) and nothing remains in the inteinal Coat of the Uterus but fmall capillary Veffels, which emit fome Drops of Blood, that are quickly flopped. BEFORE the Surgeon proceeds to the Operation, it will not be improper to prepare the Patient for it with Phlebotomy, gentle Purges, Aperitives, Abforbents; and Emollients; and that Preparation ought to be lonA get or fliorter, according to the Oldnefs of the Difcafe, and as it is more or lefs complicated with fad Accidents. Perhaps it will be laid, that fince I have proved by the Mechanifm of thofe Tumors, and Mr. Petit's Experiments, that the Defctt is rather local than tniverfal, the Preparation is needlefs; and th Surgeon ought to proceed immediately to the pecifick Remedy. That's true in fome Tumors, when blooding once or twice, and one gentl Purge are Luf V8 2 ticiCnt 29Z A Treat/fe of the ficient to prevent an Inflammation, &c. But I have mentioned fome Tumors very old, fhankcry, and ulcerated, very livid, and which are true Cancers; I have laid, that in a long time they communicate fo many faline Particles to the Blood, that it is more or lefs infedted with them. In this Sort of Tumors long Preparations arc ncccflary. Befides, Abforbents, Emollients, and Purges, ought to be ufcd even during the Cure, and a long Time after the Recovery of the Patient. S IN CE I have fecwed that all incyfled Tumors have, properly fpeaking, neither Adherences, nor Roots, I fhall depart from the Rule laid down by all Surgeons, who fay that thofe Tumors, which are not moveable, and which have Adherences, as they pretend, ought to be let alone. And I fhall follow Mr. Petit, who has fhewed the Impoflibility of the pretendcd Roots, and who believes all incyfted Tumors may be extirpated, unlefs they come to fhch a Degree, that the Surgeon can have no Hopes of a Cure. To proceed to the Operation, befides the Circumflances above-mentioned, I fhall take Notice of two others; that are very material. i. The Surgeon muft cut only the Skin and the Fat, without touching the glandulous Body. 2. He muft prdferve as much of the Skin as he can, to facilitate a fpeedy Re-union. THERE are three different Ways of making the Incifion. The firft is proper for a Tumor of a middling Size, and it ought to be longitudinal. Afterwards the Surgeon fcparates the Tumor from all the adjacent Parts; and then he brings the two Lips of the Wound near one another, to re-unite them as foon as poffible. ON the ft of April, 1718, I faw Mr. Petit perform fuch an Operation upon a Woman of eighteen or twenty Operations of SUR GER Y. 2 9 twenty Years of Age: She had a finall Tumor in the lateral and upper Part of the Nofc, near the great Angle of the Eye. The Tumor, when removed, looked like a polypous Flclh; and the Wound was cured in fix Days. Second/y, If the Tumor was larger, in the Breafls for Inflance, an Incifion ffiould be made all along the Breaft, in order to facilitate the Removal of the Gland; which would be cruel and painful: and thercforc the Surgeon makes a longitudinal Incifion upon the Tumor; and from the Middle of that incifion, he begins an horizontal one; which is called an Incifion like a T. Thirdly, If the Tumor was fo confiderablc, that it could not be removed without a large Opening, as it happens in fome fat Tumors of a prodigious Bignefs, and wherein a very bad Humor is formed; it being neceffary to eradicate that whole Tumor with its Bag, a great Opening ought to be made in the Skin; and therefore the Surgeon muff make a crucial Inciflion, and then take off the Tumor from all the adjaccnt Parts, and bring the Angles of the Skin near one another, which may be reunited by Means of a Suture. WHEN any of thofc Incifions are made upon the Breaflts, the Nipple ought to be avoided, and preferved as much as poflible; but when the Incifions arc made, the Patient muff firctch out his Arm, to bend the Pectoral; for its Surface being harder, the Gland may be feparated without hurting the Mufcle, and the Operation will be more eafily performed. IF the external Skin of the Tumor be impaired in fome Place, either by Putrefadion, or othecrwife, the Incifions ought to be direted in fuch a Manner, that the Surgeon faving as much of the Skin as he Can, may take off the corrupted Part, togcthcr with the V 3 Tuinor. 294 A Treatfe of the Tumor. But if the whole Skin, that covers the Tumor, be vitiated, tho' it be in the Breafis, the whole diftempcr'd Pap muft be cut off. TH E R E are three different Ways of performing that Operation, viz. that of the Ancients, that of the Moderns, and that of our Operators. The Method of the Anticnts confifts in pafling through the Tumor two Strings which they fallen together, to make a Loop, with which they fufpend the Tumor; and cutting round about with a Razor, the Blade whereof is faftened to the Handle with a Fillet or a Spring, they lop off the whole Pap at once. The Moderns have invented a Forceps with fnall Hooks, which they thruft into the glandulous Body, and railing the Tumor by that Means, they cut it off with a Razor, as the Antients did. THOSE Methods are too cruel and painful, and too imperfet. I fhall therefore rejpe them; firft, becaufc when the Surgeon pierces the Tumor with a Needle, to pafs the Strings into it, or when he thrufts the Branches of the Forceps to raife it, he puts the Patient to great Pain. Secondly, 'tis impoflible for the Operator, when he cuts the Tumor in that Manner, to do it fo exafly as not to hurt very much the pedoral Mufcle on which it lies, or not to leave one Half of the Gland. THE beft Surgeons now take the Tumor with the left-Hand, and raife it a little, for two material Reafons. Firft, to perceive the Vacuity between the Tumor and the pedoral Mufcle. Secondly, to brace the Skin tight, in order to cut it more eafily. THE Tumor being thus railed, the Surgeons have a fixed Place to begin the Incifion: They call it the Place of Choice, and have fixed it in the upper Part pf the Tumor bccaufe the Blood is not fo troublefome Operations of S UR G R Y. 9 5 fome during the Operation, But this Rule ought not to be ftridly obferved; nay, in fome Occafions it would make the Operation more difficult. I fhould therefore willingly begin the Operation in that Part of the Circumference of the Tumor, which gives the greateft Hold to the Operator. A Razor faflened to its Handic with a Fillet or Spring, is commonly ufed for that Incifion j but becaufe the Skin and the Fat are the only things to be cut, we fhall ufe, as Mr. Petit does, a Bif/ouri fomewhat crooked, and pierce the Skin perpendicularly, and not flanting. With fuch a Caution, the Surgeon does not lay bare the nervous CPapille and he avoids great Accidents, which are frequently attended with Death. THE Surgeon having cut about 3 or 4 Inches of the Skin and Fat, ifeparates the Tumor, and then cuts the Skin and Fat on both Sides of the Tumor, to make an end of the Operation. There is no need of cutting the Skin circularly: Nay, it is a Fault to do fo; for if the Surgeon defircs a quicker Re-union, he muft muke a longitudinal Incifion, that he may the more eafily bring the Edges of the Skin together, to make a Suture, as Mr. Petit did in an ulcerated Cancer, which no body would undertake to cure; and yet the Woman, troubled with it, was cured in a very fhort time. IF that Operation be performed in a Place where the Skin does not yield much, and the Lofs of the Subftance be fo confiderable, that the Lips of the Wound cannot be brought togethcr, to make a Suture; Mr. Petit ufes the Plaifter of Andreas a Cruce, and fays, that if a Surgeon cannot do as much good as he wifhes, he muff do as much good as he can. IT appears from our Method of curing all incyfled TumQrs, that I very much difrent from thofe, who, V 4 to 296 A Treat fe of the to purify the Mafs of Blood, and confequently to prevent a Relapfe, keep up a long Suppuration, to evacuate the bad Serofities, with which the Flefh and the Fat are infiltrated. Nay, Mr. Petit fays, he withes he could reunite the Wound in four and twenty Hours, and maintains that a Relapfe in thofe Difeafes proceeds only from a long Suppuration; Part of the Pus being convey'd into the Mafs of Blood, whilft the other comes out at all the Dreffings, which are too frequent. And indeed I have feen fome Surgeons drefs thofe Wounds regularly twice a-day; and at every Drefling they carefully wiped the finalleft Parts of the Wound, as if a kind of Glue or Varnifh, which continually runs from divided Fibers, could have done it any Harm. Befides, they fpent a great deal of Time in pulling fmall Membranes half putrified, as if they would not have come off of themitlves afterwards. Befides, during a long Drefling, the Wound remains expofed to the Injuries of the Air, which is often very bad. SUCH Drcflings occafion afterwards Phlegofes at the Extremity of the divided Fibers, which diftending the whole Wound, and particularly its Circumference, dry it up, and prove the Caufe of a Reflux of Matter, attended with feveral Accidents. In fome Tumors, the Blood being thus infeted with the Salts of the Wound, difcharge thofe Salts from fome Glands into others, diftended them, and by that Means occafion a Difeafe. The fame Salts, in other Tumors, fermenting violently in the Mafs of Blood, occafion a ~Delirium, a Leannefs of the whole Body, and Death. SURGEONs do not afcribe thofe fad Symptoms to their ill way of dreffing; but fond of their Prafice, they draw Confequences, which appear to them very plaufible. Firft, they make People believe that thofe Difeafes Operations of SURGERY. 297 Difeafes lie in the Blood, and confequently are liable to a Relapfe. Secondly, if the Patient dies, they fay, that the Part upon which the Blood was wont to empty it felf of its Salts being removed, thofe fame Salts muff needs caufe a violent Fermentation, &c. Thus they conclude that a Surgeon muff not undertake to cure incyfted Tumors, that are ulcerated and fhankery; and looking upon them as incurable, they give over the Patients. IF the Extirpation of incyfted Tumors, or their Amputation, are frequently attended with bad Succefs, 'tis becaufe the Operators have not a fufficient Knowledge of their Subjef; for there are fome Cafes, which require great Skill in Anatomy. A Surgeon ought to know the Diretion of the flefhy Fibers of the Mufcles, and the very Place where their Ligaments are faftened. That Knowledge is not fufficient: The Operator muff alfo be able to diftinguifh thofe that end with Tendons, and thofe that end with Aponeurofes, that he may give a right Prognoftick, be very wary in his Incifions, and avoid all Dangers. The Tumors, which Mr. Petit has extirpated under the great petoral dorfal Mufcles, &c. are convincing Proofs of what I fay. I fhall conclude this Subjec with the following Obfervation. Mr. Arnaud extirpated a Wen as big as a Child's Head, in the fore-part of the Knee. The Skin, that covered it, appeared very livid and inflamed. That Tumor had a Hole in it, that let out a great deal of Blood at feveral times. Mr. Arnaud being afraid that fome confiderable Vefiel was opened, put a Turniquet in the internal Part of the Thigh, to make ufe of it upon occafion. The Extirpation being made, nothing was feen in the Tumor but a vaft Number of ca-,** pillary 298 A Treatfe of the pillary Veffels, which emitted fmall Drops of Blood. That Surgeon had the Curiofity to know what hap. pened in the Tumor,and from whence proceeded thofe Periodical Evacuations, which were 1t confiderable. He found a great Number of very large and dilated Veffels; which gave him occafion to compare the periodical Flux of thofe Tumors with the Placenta, when half of it has remained in the Womb, as I explained it above. IT frequently falls out, that the Surgeon opens fmall Arteries, when he performs thofe Operations. They muft immediately be tied, or compreffed. IF I depart from the ufual Method in the Operations relating to incyfted Tumors, I depart alio fronm the ufual Method of drefling them after the Extirpation for if the Surgeon has only cut off a fmall Gland lying under the Skin, he muft only bring the Lips of the Wound near one another, bid a Servant hold them, cover the Interftice between them with a dry and thick Comprefs, and lay over it fome other Compreffes, and a Bandage proper for the Part. That Dreffing is left two or three days untouch'd, &c. I F the Wound be in a Place, where the unitive Bandage may be properly ufed, the Lips of the Wound muft be kept together by that Bandage: It muft be applied bare upon the Part, or at moft with two fmall Compreffes on the Sides of the Wound, and at fome Diftance one from another, for the Reafons above mentioned, when I difcourfed of Sutures. I the Wound is more confiderable, and the Suture has been uled to re-unite the Lips, the Surgeon muff apply bare Lint, I mean, without any Shape of Plagets or Dozels, all along the Wound, and above #w Skin in the Circuamferncc. This Method has a wonderful Operations of SURGERY. 299 wonderful Succefs: It brings perfedly well the Fat and the Skin near the pedoral Mufcle, if it be, for Inflance, in the Breafts. The Surgeon covers the Lint with three or four Compreiffes dipt in warm Brandy, and fupports the whole with a Napkin doubled three. fold, according to its Length, and the Scapulary, as I have faid, difcourfing of the Empyema. IF the Skin has been cut off with the Tumor, and the Lips of the Vv ound cannot be perfedly re-united; it muff be covered with Plagets of dry Lint, without ufing afiringent Powders, (as is commonly done,) which dry up the Part, and retard the Suppuration. Afterwards, the Compreffes and the Bandage muff be laid, as I have already faid. THE Patient ought to obferve a very fria Diet the firft Days: Phlebotomy, Purges, and all other proper Remedies are to be prefcribcd, as Occaftio requires. 4t+++++++++++++++++++++++++++++++++++++++++++++ CH A P. XXXI. Of the Squincy, in relation to the BrOanchotomy. T H E Squincy is a great Difliculty of br thing and fwallowing, occaiftoned moff times by the Diftention and Inflammation of the Glands lying near the Larynx, the Pharynx, and the Mufeles fubkervient to thole Organs. TH E Caufes of the Diflention and Inflammation of the Glands of the Throat, and of the Mufcles which dilate and firaiten the Larynx and the PhaSrynx, are either internal or external. The internal Caufes 300 A Treat;fe of the Caufes of the Diftention of the Glands of the Neck, are an Obitrution of thofe Glands, occafioned by the Thicknefs of the Humor filtrated by them, which being too grofs, cannot eafily pafs through their excretory Tubes; fo that accumulating by degrees in thofe Glands, it diftends them, and flops the Blood in their Circumference by which Means the Larynx and Pharynx are prelfed, and inflamed. THAT Humor will grow thick, either in the Blood, or in the Glands. If I fhould explain how the Humor filtrated in the Glands of the Neck grows thick in the Blood, it would be an endlefs Thing, fince I fhould be obligcd to give an Account of all the Conflitutions of the Blood, which may occafion that Difcafe; and I fhould digrefs too much from the eflential Part of this Treatife, which concerns only the Pradice of Surgery. THE external Caufes of the Squincy are fomctimes a Confequence of a moilt or rainy Air, as Hippocrates obfervcs in his XVI. Aphorifm, Section 3. or when a Man breaths a cold Air for a long Time, as it happens fometimes to thofe, who cry out, and fpeak very much, and with Vehemency. Cold Liquors drunk by People, that are not ufcd to them, may alfo occafion the Squincy. Laftly, acrimonious and acid Aliments, and extraneous Bodies fwallowed by chance, which by an Irritation in the Glands, or Mufcles of that Part, occafion an Inflammation, are the Caufe of that Difeafe. THE diagnoftick Signs of the Squincy ought to be confidcred in its Beginning, and when it is a confirmed Squincy: Thofe Signs that denote a growing Squincy, are a Difficulty of breathing and fwallowing, a confiderable Pain and Heat in the Throat, a Diftention and Rednefs of the Uvula and Tonfils, the Operations of SUR GER Y. 30 t the Thicknefs of the Spittle, the Head-ach, and a painful Stifnefs of the Neck. ON the contrary, thofe Signs that difcovcr a confirmed Squincy, are more violent. The Difficulty of breathing and fwallowing is much greater, fince the Patients generally caft up all the Liquors thro' the Nofe. The Bottom of the Throat is full of Spittle: The Refpiration is almoft fuppreffed: The Noftrils are very much dilated: The Patients can neither fpit, nor lie down, without running the Risk of being ftifled: The Face is red and inflamed: The Eyes ~fparkle; and all thofe Accidents are generally attended with an acute Fever. T H E Prognoftick of that Difeafe is more or lefs dangerous, according to the Difficulty of breathing and fwallowing; for fince Life is only preferved by the Air we breath, and by Food, it follows that the more difficult the Refpiration and Deglutition are, the more dangerous the Difeafe will be. IF the Difficulty of breathing is almoft over, and the Out-fide of the Neck appears neither diftended, nor inflamed, 'tis a Sign, the Difeafe lies in the Mufcles of the Larynx: It is then very dangerous, and the Patients generally die in a little time. IF the Difeafe be attended with a confiderable Fe-. ver, as it frequently happens, the Arteries will convey a great deal of Blood into the Lungs: And becaufe they do not receive all the Air they want, by reafon of the Inflammation lying in the upper Part of the Afpera Arteria that Blood in the Lungs not betng attenuated by the Air, will flay in it, and occation an Inflammation, and all the other Accidents that may attend it. From whence it appears that a Squincy with a Fever is much more dangerous than a Squincy without a Fever. IF 3d1 A Treatif of the iF the Patient cannot breathe but when he fits tis a Sign the Inflammation has reached the Lungs i whereby the Difeafe becomes more complicated, and confequently more dangerous. IF the Patients can hardly breathe, whatever Situation they be in, and foam in the Mouth, 'tis a Sign the Afpera Arteria is very much compreffed, and full of Serofity; which denotes a Blood very much entangled in thofc Veffels which go to and return from the Brain, and in the Lungs. The Patients are then in a fad Condition, and die in a little time. THE great Dilatation of the Noftrils is a Sign the Air ftrives with great Violence to get into the Brcaft, and that the Patient firives alfo to infpirate, which can only proceed from the firaitening of the Afpera Arteria, and the Obftrudion of the Lungs; and confequently the Patient is in very great Danger. LASTLY, if the Patients are fleepy, they feldont recover; for that Accident happens only when Refpiration is very much obftruded, and the Compreflion of the Carotides and internal jugular Veins is fo confiderable, that the Blood has hardly any Motion in thofe Veffcls; fo that the Serofity being feparated from them as well as from the Veffels of the Brain, it happens that the Brain is overflowed with it, which produces a Sleepineis. THE Brain finking, as it were, under the Weight of the Waters, and confequently the Spirits being feparated from the Blood in a fmall Quantity, it follows that the Blood will no longer be put into Motion by the fame, and will grow thick efpecially irl thofe Vefcels, where it has loft all its Motion. So that the jugular Veins being very much compreffed, and the Blood contained in them not being able to go down lower than the Difeafe, the Serofity will be forced Operations of SUR G RY. 30 forced to feparate from it, and the Blood being dry will grow hard. THE Heart conveying new Blood into the Caro' tides, and thofe Veffels not being able to difcharge it, becaufe the jugular Veins, which fhould receive it, are flopped, it will be forced to flay in the Carotides, its Serofity will feparate from it, and it will grow hard as well as that of the internal jugular Veins: In which Cafe, Death is unavoidable. This reafoning is the more certain, becaufe it is confirmed by the following Experience. MR. Arnaud performed once the Operation of the Bronchotomy: The Patient lived feven or eight Days. He opened his Body, and found the Blood of the internal jugular Veins, and the Carotides as hard as Wak. IN order to cure that Difeafe, the Surgeon muft quickly remove the Diftention and Inflammation is the Throat; and if the Squincy is only beginning, or the Inflammation reaches more to the external Parts of the Neck, Phlebotomy repeated three or four times, Clyfters, gentle Purges, and fome good Topics, fuch as emollient Poultices, Gargarifms, dc. will be fufficient to cure the Patient. The Surgeon may alfo make Embrocations round the Throat, with warm quieting Balfams, and then apply a Poultice upon it. One may even make the Patient take fome of it inwardly; and it frequently appeares by Experience, that the Ufe of it ought not to be negleded. But if the Squincy is confirmed, if the Diftention and Inflammation are rather within than without, if Refpiration is very much obftruted, and the Patient can fwallow nothing, thofe Topicks ought to be onitted; for they perplex the Surgeon, and make him lofc Time. On the contrary, he muft blood the Patient frequently and plentifully, as we flall fee in the next 304 A Treatf e of the next Chapter; and if Phlebotomy proves ineff'etual, he muff proceed to the Operation of the Bronchotomy. C H A P. XXXII. Of the Operation of the Bronchotomy. TO perform that Operation, the Patient muff fit upon a Chair, or upon his Bed, and lean upon the Back of the Chair, or the Breaft of a Servant, who holds his Head with both Hands. AFTERWARDS, the Surgeon pinches the Skin tranfverfly in that Place where he defigns to open the Afpera Arteria, which lies about one Inch under the thyroid Cartilage, and according to the modern Operations between the third and fourth Ring under the Cricoid. The Operator bids a Servant do the fame on the other Side of the Afpera Arteria, and raifing the Skin jointly with him, takes a ftrait Bifouri in his Hand, and laying his fore-Finger upon the Back of that Inftrument, he cuts the Skin about three or four Inches in Length, in the fore-Part of the Neck, the upper Angle of the Incifion anfwering the Symphijis of the Chin, and the lower correfponding with the Middle of the Notch of the firft Bone of the Sternum. AFTERWARDS, the Surgeon feparates with the fame Biflouri the bronchial Mufcles, and cuts the thyroid Glands in the middle, to lay bare the A(pera Arteria, in order to make a tranfverfe Opening with the Point of a Lancet, between the third and fourth Ring, as I have already faid. IT is impoffible to divide the thyroid Glands into two, as is prefcribed in this Operation, without cutting ' Operations of S U.R G R Y. 30 ting a vaft Number of fmall twifted Blood-Vefels, which compofe the Gland. Thofe,Veffels being cut emit Blood, which falls into the Cavity of the Afpera.rteria; which is perhaps the Reaton why that Operation does frequently prove ineffclual. WITHOUT fo many Precautions, which are more prejudicial than ufeful, Mr. Petit advifes the Surgeon to touch the Space between the third and fourth Ring with the fore-Finger of his left-Hand, and to make in that Place a Mark with his Nail, without removing it. Afterwards the Operator takes with the rightHand a Lancet, whofe Blade is faftened to the Handle with a Fillet, and with the Help of the Nail conveys it into the Vacuity of the Afpera Arteria. As foon as he perceives he is in the Cavity, he gently conveys the Lancet upon the Sides, to enlarge the Opening. THIs is the more eafy, becaufe Mr. Arnaud, who approves alfo that Method, fays, that in this Cafe the Air is fo much agitated in the Afpera Arteria, that. the Surgeon hears a confiderable Noife. Nay, #he affirms that the Afpera Arteria is very much diftended, and that the Surgeon eaily perceives when he is iner the Cavity; becaufe he feels no longer any Refittance at the Point of the Lancet, and the Air comes out immediately with a great Noife. AFTERWARDS the Surgeon withdraws the Finger of his left-Hand, to take a Stilet armed with a fmall flat Cannula, at the two Sides of which are fmall Loops, to pafs two fmall Fillets. He introduces the Stilet, armed with a Cannula, into the Afpera Arteria, conveying it with the Help of the Lancet. He withdraws the Lancet, and introduces the fmall Cannula, with which the Stilet is armed, into the Orifice of the Afpera Arteria, and ties it behind the X Neck, 3. 0 A1ieaP/e of the Neck iith te two f Syqall Ellets juft now mentioned anU t. h9, withdr4ws, the Stilet. ia Sgi.on, i s thiS Opqration, uft, avoid toudching th Iiqdcr Parr of the, Afper, Arteria, with his Jn1iruments; for it would ocaflon a Cough, whi., woWuld be very troublfonec to the Patient, a4 prevcpn tlh fahiuiig thedc Opcratuion. To drefs the Paticnt, fome advife to put into the C& uploa a litt!c Cotton tied to a Thread, to qualify thn Air, that gets int the Af/fra Arteria. Others; fhy the Cotton f)ys, and. may fall into the Afpera. A1eri u or, that it ftops it too clofely; ancL therefoc they ufce a very light Plagct of Lint, which.theyapply upon the Opcning of the Cannvla. LIafly, oý tlihrs iaintai, that the Lint-Plaget prevents the PafL fageofthc Air, and confequently that the Operation. is ufclef s; which is the Reafon why they put nothing at all A s for me, I would leave thq Cannuia open for a Moment, taking care before to kcep the Windows of the Room fhut, and to purify theAir with Fire. Afterwards, I would cover the Cannula only witha Piece of Linnen of a very loofe, Texture, that the Air might come in and get out through it. I would cover that Piece of Linnen with a Plaifter made with, Holes, and cover'd with a Comprefs of the fame Figure, the Wlho1 being fupported by fome Folds of a Lift, without pafling over the Camumla, which fhould by only cover'd with the Piece of Lingen. THAT DrCIfipg is kept on, 'till the Air refuas its CourIfe the ufual Way; which gencrally happens befoire the hii Day: And in order to know whethct ific Operation has had a good Effed, fome advife the Surgeon to lay now and then his Finger upon the CJnul- and.t to op it, that he may know. whether the Operations Of 5 0' V' A G E Y. 3e07 the Patient breathes; aý.nd wh fen the Refpirtioa isfree eniough, hc remi.oVes the Ctinnu!a;ad, edea-f yours to reunite the finall rranfvarfc O flih, ta was ade n th AJcra Azrteria and the Teg ens whtich ma Mly be ecttc~d by laying Upon the Out" fide of the Wjound foime Drops- of the (]onmdudeur'*s Balfarn, Without puttingr any Dreciling 6XVr it.s Afterw-ards, the Patlient muiA nor 1 k aliowed to fpcak$ or to (Walflow any thingr for four or Mie I-Jauts and then th~e Balfart will grow hard, and form,uiýponj t heC Wound a fmnali Cnlit, by which it, will q-u'ickly bc reunited. T HA- -r Operation is Very dangecrouis. tcw. A t-~ thors fay, they have performed it, and ~ew&r fTill, tha't it proved fuicLcefsful. The Reafion of it ketto be, beccaufe they periform, it too la 'te, and wheni the P'a*' dient is dang~eroufly Lick;5 for I am gToing, to (hew' by fome Inifances, that the Wounds of theAjprAr tetia are not mortal. Mr.Arnaud had under his Cure tvo Patienlts, whofe 'Afycra- Arteria was opein. The W ound of the fltý P atient was occafioned by a Thruff with a Knife; and lie was perfedly cured by the Care of that Suirgeon. The other Patient had been (hiot with a Piliol: The' Opening. Of the AIfperaT.ArterI'a was not paralIlel withi the Wound -of the Skin and Pief Fit fo that the Air, which- contintually can-c oult Of the Aýfre Arert both in-the lufpi r~ation; and E xpiration, i- 'chug~c xith art Obftacle on tire Sidr.c of the Skin,gcot in-to the~fa~t Cells, and occtaftoned, hin the threce or four firif D).,ýs of the Drefling, an univerfal. Epb/?4 as if he L6J beent blown, all over the B'ody; but his He~d 4calyxa nionfirou-s. Mr. zaznaud beil(ng% fen: for., dilated the XWoundl, anldldficovcred the 4/pera, HT<a:ic applied, uponl itsý Qrificc* a Piece of chwed Papecr,, anid XI z drctltd 308 A 7eat;fe of the dreffed the remaining Part of the Wound as ufually. The Patient's Swelling went off by degrees, and he perfealy recovered. Fabricius ab Aquapendente tells us in his Operations, that Albucafis fays, in the fecond Book, and 43d Chapter, that the Wounds of the Afpera Arteria are not mortal, and that he cured a ServantMaid, who had cut it with a Knife. Mr. Dionis fays, he had under his Cure at St.Germain's a Man, who had been fhot with a Piftol, at the hunting of a wild Boar. The Ball went in thro' the right-Side of the Neck, and came out thro' the left, piercing the Afpera Arteria; and yet he cured him very well. LASTLY, here follows another Obfervation to be found in Mr. Verduc's Remarks. It is well known, "fays he, that the late Mr. Binard, Mafter-Surgeon, " performed that Operation on a Baker, who being c" come to Pari', in order to fell his Bread, was af"c feded with fuch a violent Squincy, that every Bo" dy thought he could not live till the next Day; " and yet by that Operation he was able to go Home "four and twenty Hours after. ". ALL thofe Inftances feem to favour the Operation of the Bronchotomy, and to prove that it is not fo dangerous as is commonly thought but it ought to be performed, before the Patient has loft all his Strength; and all other Remedies muft be tryed before the Operation. Thofe Remedies muft not be mere Cataplafms, that are ufcd by timorous Surgeons, who are afraid of Blood; for whilft they expe6 a good Succefs from them, which never happens, when the Difeafe is come to the Degree I fuppofe, the Blood grows fo warm, and deftitute of Serofity, that it hardens, according to Mr. drnauds Obfervation above Operaton of S uGER Y. 309 bove-mentioned; and in fuch a Cafe, Death is unavoidable. THE beft Remedies to diffipate the Inflammation, and to facilitate the Circulation of the Blood in the internal jugular Veins, the Carotides, &c. is a frequent Phlebotomy in the Arms, the jugular Vein, and the Feet, as will appear by the following Inftance. Mr. Petit was fent for at nine of the Clock in the Evening to fee a young Man, affle&ed with a Squincy attended with the worft Symptoms. He blooded him plentifully, and did fo again half an Hour after; and perceiving no Abatement in the Difcafe, he continued to blood him all Night in the Arms, and in the Feet and Throat. The Patient being ftill in the fame Condition, tho' he had been let Blood thirteen Times, Mr. Petit defired a Confultation, to clear himfelf ffom the Reproaches of the Patient's Friends. Two Phyficians were fent for, who inftead of blaming him, order'd the Patient to be blooded three Times more till nine-a-Clock. After the laft Phlebotomy, the Paffage of the dfpera Arteria feem'd to be freer, he began to breathe a little, and having fwaliow'd fome Spoonfuls of Water of Caf. fia, he was perfe&ly cured, abating his Weaknefs. I F after twelve Hours, Phlebotomy fixteen Times repeated had not open'd a finall Paffage for a gentle Purge, the Surgeon would have proceeded to the Bronchotomy, wlich is always dangerous in that Sort of Difeafes; becaufe the Inflammation of the Afpera Arteria, and of all the adjacent Parts depending upon it, is very confiderable; and becaufe the Paffage of the Air is flopped; which does not happen in the Wounds of that Part. X3 IT 3 10 AT eaf -of the Ir being ufual in that Difeafe to blood the Patient very much, whether the Surgeon refolves upon the Operation or not; it follows that he mfft need'; be vcry wcvak; and without ovcr-charging his Stom.ach, he numft take itch Aiimcnts, as will keep him up, and revive his thick Jood. This will be effeted by very nourifhing Broths, Jollies, and Cock-Broth, which is excellent for thofe fic Perfons, that are very weak: It nourifhes thcm very much, keeps them up, and revives thick and flow J3ood. THEY commonly take about feven or eight Drops, or miore, in halfa Glafs of A peaoral Dict-Drink, or in four or five Spoonfuis of their Broth, or they take it alone. GENTLE Purges, Clyfters, and other proper Remedies, ought not to be negleicd. C 11 A P. XXXIII. Of the IHAREL-iP, T HE Hare-Lip is a Solution of Continuity, which happens in the Lips, either through a Defec in the original Conformation, or frol fome Accident, fuch as a Blow, a Fall, &c. THAT Solution of Continuity has been called i Hare-Lip; becaufe it makes the Lip like that ofHares, which have the upper-Lip flit. The Operation of the Hare-Lip conlifls therefore in a Re-union of that Solution of Continuity, with the Help of the twifted Suture, as Occafion requires. ACCORDING to the Definition of that Dieafe, there are two Sorts of Hare-Lip; the one born with one, a4: have faid and the other,occaion'd by fome Wound. AGAIN, Oper1It";OIS ofSI)RGFR YO AGAIN thelatter is divided into two Kinds, a, re-an-t; and an old. one. The rccent Har --ipi'sfd"cai[ lIed, wvhen the'Divilion ofthffc Lip is ifill b1l tý requires 'offl Iy -a X.e'- ýunfio6n by Means of theC 'S t-u 're, Wich rniflf be tw-iffed, if thiere- is any L ofis of S'ubýThnce, to Ik~e:ep the` -Lip s of the, Woun'd hear onh'e a-e jioffher with" the Help of 1%e.dlc's. But "if there. is O.ly --a m ere Div-ifion, the inrterfe~red S'utar~e 'N eaaily mnade in'the Middle of the Thicnf o h ip vl be fuifficient to proc-ure, a* Rc-7unwIio. I know' f t by \v o E xpe li e nce's. A von E1 d of thf- drfur teen Years of Agre fell d16wu Stairs*,;and cut her upp~er-ip 'all along the incifive Toth rdxi -the canine., aýs fajr as the Side of the Nowc, onterih-id.Imendiate'ly, 1 m'ade tw'o Stiches 'of the i~n'trfeaed Styture, one' alm`oft upon the Edge of the LIP,, to make the Re-un iion better, and the oth~er, in the Middle af the biviftion. I applied upon thaft Wotinc ai Piige cover'd with the Balfam of Peru, and.ab'ove it a Cornprefs dipt in WYine, and the comp'o.unded ban'dage, called lth~e Sling, to fupport the Oreflng.r I put between the. Gumn and the wouinded Lip a fiall Piece, of Linnen dipt in Met rofatum',' and blooded 'the Patient qn Hour after. I forbad her to fpeak, and orcr'cl e'r.'1 - 'to take nothingr bu't Broth in an opcn. and flat Spoon The next Day I rnoiffen'd tIc t)refliTzg wvinh warmI \Vine., anid put again a Piece O{'t Linnen dipt in A.Ael rofattim between the Gu and tiemid, ad thc third 'Day t dtlcffcd thec Wound in the farneI mlanner. Lafily,;ofl the fixthJ Day, after I had drelied it oncec in t\Vo Thiys,- I too'k off' the S t.itches bec auCe t he Wound was pcrfcetly rte-united. HERE fol'low-s my fecond txpcr'i ment. A Man of:,z6 Y a rs, o r t hecreaýibou Lit'S,: foughtIL With one1C QQf his flcn ýTvho threw him down, ~ihnd -wYo6u'nd him in 1,4 4-two 3'2 A Treatife of the two Places with a Stone he held in his Hand. The firft Wound was in the upper-Lip on the left-Side: It was tranfverfe; and one might fee through its Opening the Eye-Tooth, and part of the Incifive. The Lip was bruifed, and very much fwell'd in the In-fide; and therefore it reach'd about an Inch beyond the lower-Lip. The fecond Wound was about two Inches long, and lay upon the middle-Part of the Re1dus Parietalis, without laying the Bone bare. I made a Sticth in the Wound of the Lip, beginning from the lower-Part of it; becaufe it was tranfverfe, to bring it near the Nofe, and to make it tight. I thruft the Needle, which was a crooked one, (as it ought to be in all thofe Sutures ) into the Middle of the Thicknefs of the Lip, and dreffcd the Patient with a Plaget cover'd with Arcxeus's Balfam, to excite a gentle Suppuration; becaufe there was a Contufion. I made alfo a Stitch in the Middle of the Wound of the Head, taking Care to pierce only the hairy Skin, for fear of offending the Aponeurofes of the frontal Muicles, as I have faid, fpeaking of Sutures. Five Hours after, I blooded the Patient in the Arm, and found the Lip fo much leffened, that I was obliged to firaiten the Stitch a little. The two following Days, a Surgeon, who was his Friend, dreffed him only with Brandy, and the fourth Day I found the whole fo well re-united, that I cut the Sutures, and never touched it fince. T o refume the Thread of my Difcourfe, I fhall fay that the old Hare-lip is fo called, when the Surgeon has negleced to reunite the Lips of the Wound, which afterwards have been cicatrized pretty far from one another, and cannot be brought together, without cutting the hard and callous Scar, to open by that Means the finall Canals, which will inofculate with one Operations of SUR GE RY. 313 one another by means of the Suture, as I am going to fhew. B T before the Surgeon undertakes that Operation, he muft know that fome Obftacles may render it ineffetual. Some Children, for inftance, are born with that Difeafe. At that Age, they cry continually, and are only quieted by the Nurfes Breafts; whereby the Lip is always in Motion, and confequently cannot be re-united. BESIDES, Children at that Age have their Lips fo thin, and the Texture of their Skin fo nice, that they cannot bear the Needles, which are abfolutely neceffary, upon any Lofs of Subftance. Wherefore the Operation ought to be put off, 'till they be four or five Years of Age; for at that Time not only the Skin is of a firmer Confiftence, but alfo flattering Promifes, or the Fear of being always deformed, make them fuffer more patiently what is to be done for the happy Succefs of that Operation. IF the old Hare-lip was attended with a Rottennefs in the Jaw; if there was any venereal, fcrophulous, or fcorbutick Ulcer; if the Patient was very lean, and his Blood acrimonious, fait, and ferous; the Surgeon muft not attempt the Operation, before he has deftroyed all thofe Complications, viz. the Rottennefs by Remedies proper for that Difeafe; the Ulcers juft now mentioned, by mercurial Fritions, Antifcorbuticks, or by thofe Remedies, that are proper to cure the King's Evil. Laftly, lean People, whole Blood is acrimonious, falt and ferous, by Remedies proper to foften it, to abforb its Salts, and to reftore its former Confifence; which may be effected by the Advice of a learned Phyfician. MODERN Books forbid us alfo to perform that Operation, when the Lofs of Subftance is fo great, that 34 A Teatifre of the hat the divided Parts ~:annot be re-anited. I never faw a more reafonable Prohibition; for how can ay one perform what is impoffible? Oamns tell us that if the Operation was perfornred, when there is a confiderable Lofs of Subltance,.the Cute would be more pernicious than the Difeafi, becafiC the Ski would be fo diftended, r&c. that kliv~eal Words could not be articulated. IN this Cafe, the Lofs of Subflance muff needs be very greati for every body knows, the Lips are very coft Parts, that yield very mtuch, and confequently that the Operation may be performed, notwithflanding the Lofs of Subitance. Befides, not to fay thai Fabricius ab aquapendente advifest he Operatiort, Mr. Arnamud, Mr. etit, and Mr. le' Dran have performed it with very good Succefs, as I fhall fhew hereafter. WHEN the Surgecon is refolv'd to perform the Operation, it is not improper to prepare the Patient, ten or twelve Days before, by Phlebotomy, gehtle Purges, and a moifftening Diet, in order to make his Blood of a good Confiftence, fwect and balfamick, and conifqucntly the nutritious Juice, by which the divided Parts are to be re-united, well qualified for producing thc gpood Effects. To perform that Operation, the Patient muff be conveniently placed upon a Chair,' or a Bed., And becaufe we tuppofe the Circ1: mference of the Wound to be cicatrized, we mufft cut that Scar, which ftops the fmall Canals, that convey the true uniting Balfam; and therefore we ihall 1u1e two fmall Pinchers called Morailles: They have an Elbow in the MidAle, and a fmiall Ring, which reaching to the Elbow may ftraitcn them very clofely. Operations of S Uvt G E Y. 3 THE Surgeon takes with one of thofe Pincers one of the Lips of the Divifion. He adapts that Pincer in fuch a Manner, that the Scar of the Lip may not reach beyond the Pincer above half a Line, or a Line at moit, or above what he defigns to cut; and then he flraitens the Pincer with the Ring, to keep the Lip from ftirring. THE Surgeon muff do the fame, with refpe& to the other Lip, and the other Pincer. Afterwards, he raifes them both towards the Nofe, that he may perceive, and brace a Ligament, which faftens the Lip to the Gum. He cuts it to perform the Operation more eafily but he muft take Care not to affed the Gum, for fear of laying bare the Jaw-bone, which would always r ^;ain bare, according to the Opinion of many Authors. The Surgeon muff alfo avoid, as much as he can, to cut upon the Lip, though the Accident would not prove fo bad. I N order to prevent thofe two Inconveniences, I thall follow the Diretion of Mr. Arnaud, that able Praditioner. He cuts that Ligament or Bridle with Sciflars pointed at both Ends. That Inftrument cuts equally both Sides of the Ligament, and by its means the Gum, or the Lip, may be better preferved, than with the Bif/ouri recommended by Authors. THAT fmall String being dcefroyed, the Surgeon muft with the fame Sciffars cut about half a Line of the upper Angle of the Divifion, to deftroy all the Callofity, which would otherwife leave a fmall Hole in the upper Part of the Hare-lip. AT the fame time, if the Scifars cut well, the Surgeon fhall cut the Scar, which reaches beyond the Pincer, taking the Pincer with his left Hand, and the Sciffars with his right; I fay, he is to cut the whole Cllofity at once, and evenly, taking care not to cut S: - * - * Q 316 A Treat/;e of the too much of it, but as much as is neceffary to open the fmall Tubes, which are to inofculate with thofe of the oppofite Side. Afterwards, the Surgeon will take the other Pincer with his right Hand, and cut the oppofite Scar in the fame Manner, taking care that the two Strokes of the Sciffars may end towards the firft Divifion we at firft made in the upper Part of the Wound, and end in a very acute Angle. WHEN the Surgeon has cut all the Callofities, that might prevent the Re-union of the Hare-lip, he muft loofen the Rings of the Pincers, and remove them from the Lips, which they hold. The Operator need not be concerned at the Blood, that comes out: It ftops eafily; befides, 'tis not improper to let the Wound bleed a little, in order to clear the Tubes. A F T ERWARDS, the Surgeon muff think of reuniting that Divifion. To that End, Surgery affords us the twifted Suture, fo called, becaufe the Thread is twifted about two or three Needles. THOSE Needles being very fmall, and the right Hand not being able to drive them fafely, nor the left to fupport the Part, the Surgeon muft have recourfe to fome Helps proper for both Hands. Let him ufe for the right Hand an Inftrument, into the Groove of which he fhall put the Head of the Needle; but he muft firft of all wrap about it a fmall Piece of Linnen, or Paper for in whatever Manner the Inftrument be grooved, it cannot hold the Needle faft enough. When the Surgeon has furrounded the Head of the Needle with a fmall Piece of Linnen or Paper, and put into it the Groove of the Inftrument, which is therefore called a Port-needle; he firaitens the Inftrument with a fmall Ring, &(c. THE other Help proper for the left Hand is a fmall Cannula, generally made of Silver, flat on that Side where Operations of SURGER Y. 317 where it is applied upon the Parts, to be tighter, and fplit in the oppofite Part to let in the Thread. I thall defcribe tihofe Inftruments at the End of this Treatife. THE Surgeon, being provided with thofe Initruments, fhall make the two Lips of the Wound level one with another, and bid a Servant hold them in that Situation, who fhall prefs the Cheeks of the Patient, as much as is neceflary to keep the Divifion perfccly even, and in fuch a Manner, as not to difturb the Operator in his Operation. AFTERWARDS, the Surgeon fhall lay the Ring of the Cannula in the lower Part of the Hare-lip, at two Lines diftance from the Opening, and on the right Side of the Patient; and laying the Point of the Needle, which he holds with the right Hand, likewife at two Lines diftance from the Divifion, in the lower Part, and on the left Side of the Wound, he fhall pierce both Lips at once, conveying the Needle into the Middle of the Thicknefs of the Lips, as much as he can, without quitting the Port-Needle: He withdraws the finall Ring; and the Inftrument leaves the Needle: He lays again another Needle upon the Portneedle, always furrounded with a fmall Piece of Linnen or Paper, that the Port-needle, which muff comprefs a hard Body, may find a foft intermediate Body to help it in that Ation. This Mechanifm is very well imitated by thofe Workmen, who make Ufe of the Vice; for they furround with a Felt the hard Bodies they have a Mind to fqueeze, that the Vice may have a better hold, and the Body may be tighter. The Surgeon flall therefore pafs that fecond Needle thro' both Lips, and in the fame Manner, laying it between the firft Needle, and the upper Angle of the Wound. To bring the Lips of the Wound more exafly near one another, and keep them-fo, a Thread, or two or S three Aý T7reati/e of the thrte finall Needltcfis of waxed Silk muff be tWif*ect aboutthe N:eedles. Some begin with the lowci; Needle, and otheis with the upper one, which id iiffverent. I would' chufe to apply the Middle of the waxed Thread 'about the lower Needle, and crofs it between the upper Needle, to furiound it after'wards; as Well as the firff. I would do the fame with the third, if there was one, and go down towards the low. er Needle, where I would flop the two Ends of th. Thread with a -ingle Knot, and a fmall Loop. BEORE the Surgeon proceeds further, it wiltot be amifs to Wvafh the Patient's Mouth with proper Liquors, fuch as a Barley-Deco&ion with Metrofartm, injeted with a Syringe; and then the Surgeon cuts the Points of the Needles with incifive Tongs, and puts fome finall Pieces of Spunge under the Needles. Mr. Arnaud prefers them to the Compreffes, that are commonly ufcd, becaufe, fays he, they may be better adapted to the Figure of the Part. Mrt, Petit does not ufe the Helps, which I have faid to be proper for both Hands: He thinks they. are too cumbecrfome and inconvenient; and therefore he has contrived Needles like larding Pins: They are large, and give the Surgeon fo great a hold, that he may be without the Port-needle and the Cannila. AFTERWARDS, the Drefling begins with a fmall Piece of fine Linnen dipt in warm bel rofatilm, and adapted between the Lip and the Gum, in that Place where the Frenum has- been cut, to prevent the two Parts from flicking to one another. He goes o'n with the Drefling, pouring upon the Suture fome Drops of the Comma~~ ur';s Balfam; which is the moft proper, bccaufc as it dries up, it forms a Cruft, by which the Air is kept out, to that it cannot corrupt the nutritious Juice. The Surgeon applies a finaai oft Plaigetr dipt' Opera/ions of U R GPR T. ff in thc fame ialfam, and a- fEimal Compref bmfrewhat long, imbibed likewife with that MedicAnie t. He fupports the whole with a Bandage called the Slin, or with the End of a Fillet, a Foot: and A half long, and about tltee Inches broad, ani cut in the Middle, that the Nidfrils and the Moluth may have a free Refpiration. THE Bandages muft be pinned to thc PatienC'EsC4p but it bught to be obferved, that- the Suturd alorte is more than fufficient to keep the Lips of the Wound united together, and confequently that the Blndag is only defigned to keep in the Renedies, aitd'not to prefs upon the Parts; and t erefo e that it mft be tight for no other Reafon thanti to keep the Drtiffling upon the Wound. According to this PraaiCe, we rejctt the unitive Bandages% which Authors advife us to bind very carefully; anrd we prove by denionflra-. tive Reafons, grounded upon the Strudure of the Part, that they muff needs be very prejudicial, as well as the Sling and the notched Bandage, when they are too tight. Here follows the Reafon of it. All thofe Bandages have their refting Point upon the- Needles, and cannot be firaitened, but the Needles - wilt prefsthe Inlide-of the Lip againft the Teetih; which will occafion a Bruife in the In-fide of the Lip- atten7 ded with a Pain, and a Reflux of the Spirits towards the Brain, that will quickly be follow"d by a Return towards the Part; and coifequently the Pain will increafe more and more, and be attended withi an Inflammation, an Eryfisela,- a Fever; Convulflons, and a Lirzwm. In a Word, to preferve the Patient from Death, the Bandage and the Suture muft imn mediately be untied, if thofe bad Symptoms Contiwe ever - o- little. THE 3 20o A Treatfe oJ the THE Patient muff go through a flri& Courfe of Diet, being only nourifhed with Broth, to be taken with an open and flat Spoon. Some Spoonfuls of Jelly muft be put into the Broth, to fupport him better. He muft be blooded two or three Hours after the Operation, if it be thought proper. He muft neither fpeak nor laugh, nor cry, nor do any thing, that may Ipat the Lip into Motion. He muff take fome Clyfters now and then, and the two or three firft Days in the Evening an Emulfion, or Julep, with fome Laudanum, or Syrup of Poppies in it, to quiet the Blood and promote Sleep. IF there has been no Occaflon to take off the Drefling, it muft be taken off the fecond Day; and the Surgeon muff take care not to pull the Plaget, or the Comprefs, but to imbibe them with warm Wine, that they may come off almoft of themfelves. If the Thread is too tight, or too loofc, it muft be made loofer or tighter, as the Cafe requires, and the Wound muft be drcffed in the fame Manner as I have already faid. THE following Days, it will be fufficient to moiften the fmall Comprefs, and the Plaget with the Balfam, without taking them off from the Wound; and Care ought to be taken to put every Day a finall Piece of fine Linnen, dipt in Mel rofatum, between the Gum and the Lip. On the fifth or fixth Day, the Surgeon muff take off the Drefling and if he perceives a Re-union, and that the Needles begin to fhake, he muft remove the Thread, and leave only the Needles one Day longer, if he thinks fit. Laftly, when he takes them off, he muff convey two Fingers of his left Hand near the Lip, on the Side of the Needle, for fear of breaking that Re-union, which is fill very tender. Afterwards, he is to ufe a fmai Operations of SUR GERY. 31t frnall Syringe with a very fmall Siphon, to inje& fome Balfam of Fioravanti into the fmall Eyes of the Needles, to drive out the 'Pus, and clofe them up again. Befides what has been faid, a fmall and thin Comprefs, dipt in the Balfam of Fioravanti ought to be applied upon the Scar, and fupported by the unitive Bandage, which is now very proper, fince the Suture is removed; and it will bring the Lips nearer one another: This a Servant ought to do at every Drefling, by prefling the Cheeks gently. M R. Arnaud performed that Operation upon a Man, who had no fore-Teeth, and confequenitly he wanted a propping Point to facilitate the Paffage of the Needles. He Iupplied that Defet by putting under the Lip a Plate of Lead broad and thick enough to refift the Pafiage of the Needles, and to ferve as a propping Point. CHA P. XXXIV. Of Cancers, and (hankery Puflules which happen fometimes in the Lips. T E Glands of the Lips, as well as thofe of other Parts, are fometimes diftended, and form Tumors or fhankery Puftules, which oblige the Surgeons to take off' a great deal of the Subfiance of the Lips, to remove the Difeafe intirely, and deliver the Patient from an Evil, which would be attended with very bad Confequences. 'Tis true, we are forbidden by Authors to make the twifted Suture in the Lips, when there is a great Lofs of Subftance: Y But 31 A Treatife of te But fince I have already proved, that wherevet the Parts are loofe, and yield much, they may be brought together, and a Suture may be made in them; I fhall not fcruple to take off a great deal' of Subftance from them, to remove the Difeafe with which they are affcaed, and to make the twifted Suture in order to re-unite them, as it will appear by the two following Inftances. A Perfon, who was a Patient to Mr Arnaud had a Cancer in the lower Lip, almoft over againft the Eye tooth. That Cancer was at leaft as big as 11 Egg. To take off that fhankery Tumor; without leaving any thing, that might occafion a Relapf, that Surgeon put the fore-Finger of his left Hand between the Gum and the Lip, and conveying a Braiich of probe Sciffars upon his Finger, he made an Incifion on the Side of the Bafts of the Tumor, the Diretion whereof was oblique, and about two Inches long. Without moving his fore-Finger from under the Lip, he conveyed it on the other Side of the Tumor, to make another Incifon, which was indeed oblique, but quite oppofite to the firft, fmnce the upper Part was at a great Diftance from it, and the lower one was next to it, fo that both Incifions together made an Opening, whofe upper Part was an Inch in Diameter, and the lower one reprefented an acute Angle. MR. Arnaud removed the whole fiankery Tumor by the Wafte he made in the Lip; but he quickly repaired it, by bringing the Lips of the Wound near one another, and pafling a Needle towards the lower Part of the Divifion, obferving the Circumftances above mentioned, when I fpoke of the Hare-lip. Afterwards, he put a fecond N eedle towards the upper and middle Part of the Wound and a third very fine Operations of S R G E R. 3 fint Needle on the Edge of the Lip, to make the Re-union more perfet. THERE was no Need of any Help for the left Hand, becaufe the Hand alone could refift the Impulfe of the Needle. Mr. Arnaud twifled fome waxed Threads about the Needles, and laid the Drefiing, as tis pradticed in the Hare-lip; and that Opei'ation had a wonderful Succefs. The Patient was cured in a Week; the Needles fell off almoft of themfelves: They might have been taken off fooner; but they were left on, that the Divifion might have more Time to be re-united. Mr. Petit, and Mr. le Dran were confulted about that Operation. MR. Petit took off a fhankery Pimple lying in that Place where the Zygomatick Mufcle paffes, a little above the Clofure of the Lips. He put a Finger under the Lip, as I have faid before, and conveying probe Scif~trs upon his Finger, he cut the Skin, and tle Flefh of the Lip, that touched the upper Part of the Tumor, I fay, he cut them almoft horizontally, and a little beyond the Tumor; and without removing his Finger from under the Tumor, he made -another Cut with the Sciffars, which began in the fame Place as the firft, and.ended at the lower Part of the Middle of the Tumor. Laffly, he made a third Cut with the Sciffars, which began at theEnd of the latter, and made a very acute Angle with the Extremity of the firft Cut; fo that thofe three Cuts, which wholly took off the Tumor, were like an 1 -fofceles Triangle. AFTERWARDS, Mr, Petit made it his Bufincfs to re-unite that Wound, bringing the Lips near one another, and holding them in that Situation, with the Help of the twifted Suture. He put the firft Needle Y 3 i4i 314 A Tee'at/e of the in the Place whcrc the Lips join, to lcffcn the Deformity: He began to flop it, by twifting the Thread about it: Afterwards, he placed the fccond Needle in the Angle of the Middle, to bring over the inferior Lip, which was more extended than the upper one: He put a third Needle towards the Angle oppofite to the Clofure of the Lips, and introduced thofe Needles with the waxed Thread, as in" the Hare-lip. IF in' fuch a Difeafe the three Needles fhould leave:any Loofcnefs in their Interval, the Surgeoni muft pafs fome Needles into it, to bring them over, and by that Means the two Lips of the Wound will be exaaly re united. I r ought to be obfervcd that the Needles mufft be driven into the very Middle of the flefliy Fibers, that the Re-union may be better made, and the Suture be fironger. The Needles muff be of Silver, and pretty long, becaufe the Contradions of all thofe Mufcles make fometimes great Efforts; which ought to be minded in the Hare-lip. CHA P. XXXV. Of the Polypus. B Y a 'oPypus in the Noftrils we mean a feenmi ing flefhy Excrefcnce, whofe Bafis is narrow; and which, as it grows bigger, is commonly divided into many Branches. The Surface of that Excrcfccnce appears very fmooth; and obmetimes it grows fo big, that it flops the Cavity of Operations of SUR GER Y. 315 -of the Nofe, and hinders Refpiration. Nay, fometimes fome Branches of it fpread theimfclves outwardly, and others get into the Mouth, behind the Partition of the Palate. TH E Caufes of the Polypus, according to moft Authors, are the internal Mcrnbrane of the Nofe, which, fay they, is very thick, fpungious, penetrable, and imbibed with a tenacious and glutinous Humor; fo that a pituitous and crude Blood, as they fhppofe, impregnated with vifcous Particles, either from an indigfitcd Food, or from other Caufes, being forced to run thro that Membrane, obitrufts, and relaxes it, divides fome Fibers, and by that Means occaftons a Polypus. I don't know whether this Explication be fatisfa~tory, and fufficient to refolve all the Objedions,that may be raifed. THE pituitous Membrane of the Nofe is indeed moiflened by a thick Lympha, which keeps its fmall nervous Papill pliant, and ferves, as it were, initead of a Varnifh to fecure them from the dangerous Approach of odoriferous Bodies. But it does not follow from thence, that the thick Lympha, which moiftens the whole internal Membrane of the Nofe, divides and relaxes its Fibers to fuich a Degree, as to occafion a Polypus; for if this was true, the Polypus would have its Original in the whole Extent of the pituitous Membrane, which has fo many different Foldings; and it could never be cured, either with Caufticks, fince they could not be conveyed into all the Foldings of that Membrane, or by Extirpation, fince it would always be attended with an Heworrhage on fo many Sides, that it could not be flopped. And yet we fee the Contrary, fince we know by the Operation, and by Y 3 thc 326 A Teat;fe of the the Examination of a 'Polypus, that it has its Original only in a certain Part of the Nofe, and that its Bafis is ufually very narrow. B ESIDE S, if the pituitous, crude, and vifcous Blood, which circulates in that Membrane, was together with that Membrane the Caufe of the Polypus, it would take up the whole Membrane, as I have already faid, fince that raw and vifcous Blood does equally circulate in every Part of it. But befides the Impoffibility of the thing, all Phyficians and Anatomifts are agreed that the Blood is the fame in all the Parts of the Body; and that the Blood conveyed into the internal Membrane of the Nofe, for Inftance, is not more pituitous, crude, and vifcous, than that which is conveyed to the Feet. Therefore, the Blood of it felf is not more apt to occafion a Tolyfus in the Nofe than in the other Parts. ONE may draw from thofe two Arguments fome Confequences, which plainly fhcw that the pituitous Membrane of the Nofe, and the Blood cannot be the only Caufes of a Polypus. ALL Authors acknowledge that there are hard, fchirrous, and fhankery Polypus's; that they ulcerate fometimes, and that they are painful, and generally incurable. S INCE thofe Difeafes are fo like a Cancer, 'tis likely their Caufe is the fame as that of other Cancers, which are all incyfted Tumors, as I have Ihewed at large, when I difcourfed of thofe different Difeafes and I faid then that all thofe Sorts of Tumors began with a glandulous Tumor. THIS Opinion appears the more probable, becaufe the pituitous Membiane of the Note is provided with a vaft Number of fmall Glanks, the Tomentum whereof or the Veficle, as fome will have it, is imbibed, from Operations of SURGER Y. 2,7 -from the very firft Conformation, with a Humor perfealy like the thick Lympha, which moifltens that whole Membrane; fo that the Blood running thro' the fmall Glands, leaves in them that Serofity which we obferve in the internal Membrane of the Nofe. IF any of thofe fluall Glands happens to be diftfen ded, by reafon of the nutritious Juice, and Lympha, that are grown thick in it, either thro' their own Defeds, or thro' the bad Difpofition of the Gland it felf, there will follow an Obitrudion, xwhereby the Courfe-of the Liquors will be flopped, and the Gland more and more diftended. THAT Gland being fwelled, it follows that.the Membrane will be very much diftended, and will firongly comprefs the VeffTels, that convey theBlood or the Lympha into them; but thofe Veffels which convey the Blood, will be lefs comprefkfd, efpecially the Arteries, becaafe they have a Motion of Dilatation and Contration, which forces the Blood into the Gland. But the lymphatick Veffcls, efpecially thofe that creep upon the Membrane of the Gland, being conpriffed, will let out thro' their Pores the Scrofity of the Lympha, whereby that Membrane will grow loofe, firetch out, and yield to the Impulfe of the Blood and nutritious Juice, the more becaufe they flay longer in it than ufually. Thus the Gland, that forms a 'Polypus, will grow by Degrees. A ND becaufe the Fibers of the glandulous Membrane relax more and more, by reafon of the Scrofity of the Lympha, which continues to diffufe it felf, and of the nutritious Juice, which accumulates continually, 'tis plain they muft yield to the Impulfe of the Blood, and grow very bulky; and therefore the Polypus will encreafe more and more. Y 4. SINCE 328 A Tr eat fe of the SINCE the Serofity, that is diffufed by reafon of the Diftention of the Gland, falls only upon few Fibers, 'tis certain there will be but a fmall Number of them relaxed, And becaufc the Bafis of the Polypu is more or lefs extended according to the Quantity of the relaxed Fibers, 'tis plain the Bafis of the Polypus will be narrow. Bu T the Fibers of that Part which rifes, and reaches into the Nofe, being very much relaxed, will be apt to fpread upon the Sides, efpecially towards the Out-fide, where the nutritious juice moves more flowly than in other Parts, whereby the Polyput will be broader at its Extremity. THE Gland cannot be difiended, without comprefling the excretory Dudts of the adjacent Glands; which will alfo occafion their Diftention; and the more eafily, becaufe thofe fmall Glands lie all in Clufters like Bunches of Grapes; fo that the firft that is diftended, prevailing over the others, will grow larger, and form the Body of the Poypurs, whilfi the others form the Feet, or the Branches, in the fame Manner as I have fhewed that the Glands lying near fhankery Tumors, being compreffed, diftend themfelves, and form the pretended Roots of the Cancer. LASTLY, becaufe thofe Glands are covered with a finooth and polifhed Membrane, and becaufe that Membrane has undergone no other Change but a greater Growth, it follows that it muft remain fmnooth, and the Polypus will have an even Surface. THE diagnoflick Signs of a Polypus are fo obvious, that the Sight iMay judge of them; for if the Patient bends his licead backwards, the Surgeon perceives in his Noftrils a fmiooth and polifh'd Tumor, fom5times of a dark-red, at oher times of l more ively red, and frequcntly Operations of SURGERY. 319 frequently of a whitiflh Colour, with a Motion anfwering the Infpiration and Expiration. If the 'Poly, pus be confiderable, the Nofe will be larger than ufhal; the Patient will fpeak through the Nofe, and frequently open his Mouth, efpecially in his Sleep, to breathe more eafily. THE prognoftick Signs of a Polypus depend upon the Nature of the Tumor. A hard, livid, and painful Polypus is of.the worft Sort, and generally becomes fhankery; for it cannot become fo 'till the Blood is grown thick, and impregnated with grofs Salts, which for want of Serum getting rid of the Blood, will acquire a Motion, and corrode the Fibers of the Membrane and Gland. Authors forbid meddling with thofe Sorts of Tolyfus. Thofe that have Feet or Branches in the Mouth, are hard to be cured; but thofe that are free from Pain, reddifh or whitifh, without any Hardnefs, and feem to have but few Adherences, may be more cafily extirpated, cfpecially when they are not rooted far in the Nofe. Befides, one may judge of them by the Patient's Facility of breathing. CHA P. XXXVI. Of the Operation of the POLY PU S. SPolypus is deflroyed two Ways by the Operation, and by the Cauftick. Mr. Petit advifes to confume thofe, that are hort and broad. Thofe that may be extirpated, may alfo be confumed. Mr. Thibaut ufes a Cauftick, which has an immediate Effete. He takes two finall Plaiflers, and applies them inwardly between the 'Polpus and the intcrn4l 330 A Treatife of the ternal Coat of the Nofe, to keep the Cartilages of the Nofe at a Diftance from the Cauffick. Afterwards, he makes a fmall Sprinkle, with which he takes Butter of Antimony, laying it upon the Polypus, and taking care not to affeat the adjacent Parts. The Polypus muff be wafhed with Water becaufe the Cauftick would occafion fbme Difordcr: That Remedy works immediately. IF we judge of the Extirpation of the Tolypus, according to what Fabricius ab Aquapendente fays of it, we fhall conclude that it may have a good Succefs; fince that Author, who gave us the Figures of the firft Forceps made uie of to perform it, affirms that he did it very often, without any Accident enfuing from it. However, we muff not blindly follow the Prefcription of that great Man, and we ought to mind the wife Counfel of Mr. Arnaud, who fays, the Extirpation of a Polypus has fometimes been attended with fuch a confiderable Hemorrhage, that it was impoflible toftop it; and the Patients died, without any Poffibility of being relieved. Wherefore the Surgeon ought to ufe all imaginable Care, to prevent that Mifchief. BEFORE the Surgeon undertakes that Operation, it will not be amifs to prepare the Patient for it; and becaufe we are afraid of an Hemorrhage, that Accident may be prevented in a great meafure by Phlebotomy, which leffens the Quantity of Blood. GENTLE Purges muff alfo be ufcd, to clear theprime vie, and difpofe them to receive Aperitives, which will divide the thick Lymph, whereby the Gland was diftended, and alfo to abforb the prevailing Acids. IN order to make thofe Remedies fuccefsful, a wife and experienced Phyfician ought to be confuqted, who, in concert with the Surgeon, fall prcfcribc Operatiols of SURGERY. 33 I fcribe the Remedies one after another, beginning with the mildeft. To perform that Operation well, according to Mr. Arnaud's Advice, the Patient muft fit upon a Chair leaning backwards, and placed in fuch a manner that the Surgeon may fee as much of the Noffril and Po1Opus as poffible. A Servant keeps the Patient in that Situation, laying his Hands crofs-wife upon his Fore head; and other Servants hold his Arms. AFTERWARDS, the Operator takes a Forceps blunt at the End, or Mr. Petit's Forceps, which I fhall defcribe in my Treatife of chirurgical Infiruments. He holds it with his right-Hand, to introduce it into the Nofiril, where the 'Polypus lies: He takes hold of the Tumor pretty far, and towards its Bafs; and then draws it away by degrees, moving the Hand up and down. When there is a fmall Part of the ~Polpus out of the Noftril, he makes a Ligature to it with a double and waxed Thread; and then he takes hold of the Tumor with the Forceps, to draw it out a little more. He makes a fecond Ligature above the firft; and if he thinks the Polypus can ftill bear a little more pulling without coming quite away, he draws it a little, and makes a third Ligature. He cuts the Polypus under this laft Ligature, and by that Means flops the Hemorrhage, which has fometimes been fo confiderable, that the Patients have died of it. The remaining Part of the Polypus falls by the Suppuration, in the fame Manner as it happens to the fpermatick Vefficls in the Operation of the Cafiration. This, I think, is the fafeft Method to extirpate a Pof lYpus. IF the Operator has wholly extirpated the Pol/pus, and fome Artery lets out a great deal of Blood, he muft flop it immediately, cndeavouring to find out that 33 t A7reat;fe cf the that Artery.; and he muft lay, upon it a Dozel tied, and dipt in fome fliptick Water, of Colchotor and Bole t.Armenic, and above that.Dozel feveral others, that the Artery may be fufficiently compreffcd. THE Blood beingtflopped, the Surgeon dreffcs the Patient, filling the Wound, for the Space of a Month pr fix Weeks, either with Tents or Dozels covered with fome deficcative Powder, to dry up and comprefs all thofe Parts, that might occafion a new TuMnor. ALL this while, the Surgeon muff continue to ufe the Remedies, which J have prefcribed for the Preparation,. The Patient muft keep a ftria Dict: He mutl not be allowe4 any thing, that is falt, fpiced, and acidt and confequently the Ufe of mott Wines is pernicious. The Surgeon mufft forbid him to eat any Ragoo, or any thing hard to be digefled, and prcfcribe to him fuch Remedies and Liquors as contain many volatil Alkalies. Hot mineral Waters are of great Ufe. I r the 'Polypus comes down very low into the Mouth, and protrudcs the Vale of the Mouth very forward, it muff be extirpated thro' the Mouth. That Operation was lately performed by Mr. 'Petit, upon a Child of twelve or thirteen Years of Age. The Iolypus had been precceded by fuch fad.Difeafes, and was fo large, that the Succefs of the Operation was defpaired of. The Difeafes with which that Child was affetcd, were a fcrophulous Blood, and the venereal Difeafc. In order to cure the laft, I ufed Bathing, Fridions, and other Remedies, being aflifted with the Advice of Mr. Le Roux, fivorn Sargeon of 'Paris, and very much experienced in thofe Sorts of Difeafcs. The Mcrcury raifed a Fermentation of the Blood and Lympha in fome Parts of the Polypus, which occafioned finall AbfLelCs in it, and ncrcafed it to fiuch a Degree, that it Operations of SURGERY. 333 it flopped in a great Meafure the Paflages of the Air and Food: So that the Patient not being able to live long, the Operation was refolved upon, and performed by Mr. Petit in the Prefence of feveral Surgeons of Taris. He began with cutting the Vale of the Mouth in two Places, that he might more eafily touch the Ligament of the Polypus: Afterwards he cut the Polypus, which adhered by a kind of Stalk of the Nature of Cartilages to the Vomer, and on the right Side towards the Aquedut. In the next Place, he plucked it out with a fmall Iron-fpoon, and his Fingers. All thofe that flood by, were furprifed to fee a flefhy Tumor as big as the Fift, of a triangular Figure, and like a large Gizzard come out of the Mouth of that Child. After that Operation, the Patient fpoke his Words very plain, and flept quietly; which he could not do before: And, what is moft remarkable, he was perfetly cured. C HA P. XXXVII. Of the Fiftula Lacrimalis. I Have already faid, that by the Word Fiflula we mean a deep Ulcer in fome Part of the Body, the Bottom of which is large, and the Orifice very fmall, generally attended with a Callofity, which lets out an acrimonious, fanious and ferous Matter. HOWE VER all thofe Chara6ers do not always appear in the Fflula Lacrimalis; and therefore we define it, a Colletion of purulent or ferous Matter in the lacrymal Bag generally without a Callofity, frequently without any vifible Orifice, fomctimes attended with a finall Tumor in the gret Corner 4a ATrreaiAeoft1he '~ornet of the Eye, which emits, when preffedi foinetimes a purulent Matter through' the lacrymal Bag, and frequently a Matter perfealy watery. THOSE Parts of the Body, that are moft fubje& to Fiflulas, lie generally near the Receptacles, or even Refervatories of fome Humors, which by their Alte, ration produce a Fifula. We have feen elfewhere, that the Fat and the Veffels lying near the Anus do very much contribute to the Formation of the Fifltla in Ano; and it frequently happens for the fame Reafon, that the Glands, the Blood-veffels, and the Sinovia altered in the Joints, occaflon that Difeafe: And if a Fifula arifcs fometimes in the great Angle ofthe Eye, 'tis becaufe there are already fome Tears that may be the Caufe of it. ACCORDING to this Syftem, the Fifula Lacrymalii is occafioned by the Alteration of the Tears. But becaufe we have proved that the Fiflulas of the other Parts are fometimes a Confequence of their Diforder from fome external Caufe; it follows that a Blow, a Fall, a Compreflion, &c. frequently occaflon a Fifula Lacrymalis, as I fhall explain hereafter. THE Fifula Lacrymalis is alfo frequently a Confequence of the fmall Pox; and then, befides the ill Difpofition that may happen to be in the Blood and Tears, fome Grains of the Pock that have occafioned Ulcers in the lacrymal Bag, or in the lacrymal Points, will be the immediate Caufe of that Fifula. THE Alteration of Tears, that can produce an Abfcefs in the lacrymal Bag, and all the Accidents following upon it, is, in the Judgment of the ableft Phyficians and Surgeons, their Acrimony and Saltnefs A Chara&er, which is common to them with the Alteration occafioned by the pernicious Ferments, that corrupt the Blood of People affced with the King's Oper5atls of S JS RGtR 'At.3 King's Evil, the Scurvy, the venereal Difeafe, &r: And therefore we frequently fee that the Pi'fula Lacrymalis cannot be cured without great Difficulty. THERE is no need of being well skilled in natural Philofophy to explain how acrimonious, falt and corrofive Tears, may occafion an Abfcefs, and confequently a Fifula, fince their faline Particles being very grofs, and free from Serum, and flaying a long time in the lacrymal Bag, mufft needs irritate that Membrane very much, and occafion a violent Flux of Spirits towards that Part, which ftraitening it on all Sides, will firongly comprefs the Blood-vefFes, and quickly occafion a confiderable Inflammation in that Bag. TEARS remaining a long time in the lacrymal Bag 'by reafon of the Inflammation, which keeps them on all Sides from coming out, occafion a greater En-. creafe and Acrimony of the Salts, whereby the Membrane will be more irritated, being already diftended by the Inflammation: And confequently the Flux and Reflux of the Spirits being quicker and more frequent, the Inflammation will encrcafe to fuch a Degree, that the Blood-veflels, efpecially the Arteries, will break, as well as the lymphatick; and from that unequal Mixture of extravafatcd Liquors there will arife a Fermentation, which will produce an Abfcecfs. I V acrimonious, falt and corrofive Tears, can be the Caufe of fo much Diforder, it follows that whatever makes them fo, may occafton a Fltfula. And becaufe Anatomy teaches us that Tears' are feparated from the Blood thIough a Gland lying in the upper Part of the Orbit, we ought to infer fro,& thence that whatever communicates a great deal of Saltnefs and Acrimony to the Blood, may alfo communicate it to Tears. This we frequently obfcrve in hofe, SwhOr dA Treat e of the ho are affe&ed with the above-mentioned Ditfeaes i or they have other Indifpofitions, fuch as the Ophthalmy, the Ankylops, &c. THE F/flula lachrymaleu proceeds alfo from other Caufes; for it is frequently occafitoned by I)ifeafes, which happen near the lacrymal.Bag for inflance, under an Ulcer in the Nofe, which corrodes that Bag, and fo produces a Fiflula. A Polypus comprefling the nazal Condut, hinders the Tears from coming down into the Nofe; and thofe Tears being detain'd in the lacrymal Bag diftend it, are vitiated, and are able to occafion the Diforders, which I am going to mention. AN Ankylops that fuppurates, goes, as foon as it is opened, by the Name of Aigilops, a Difeafe to which Goats are very much fubjedt; and when it is ill dreffed, it turns to a FJflu/a Lacrymalis. Therefore bad Dreflings do alfo contribute to form a Fiflula, as it may eafily be proved. Thofe who have a flat Nofe, and depreffied, are fll1 more fubjet to a Fiflula Lacrymal/ than others, for theReafons abovementioned, when we fpoke ofthe Poylpus. A Blow, a Fall, &c. upon that Part, may alfo occafion fuch a Fifula; becaufe external Caufes bring an Inflammation upon the Bag, whereby the Blood is flopped in the Part, breaks the Veffels, extravafates in the Bag it feif, ferments, and produces a Fiflula. There are other Sorts of Fiflulas; one called, by Mr. Petit, a Hernia of the lacrymal Bag, which is occaftoned by a fmall Inflammation proceeding from a Blow, a Fall, or a Compreflion. And then the lymphatick Veffels being ery much comprefled, let out through their Pores the Serofity of the Lympha, which relaxing that membranous Bag, dilates it, and by that means a Tumor is fometimes formed outwardly, and fometimA inwardly. THI OperattON of S U R GER Y. 3 THAT Difeafe has been called, by a modern Oculif, A Dropfy of the lacrymal Bag; becaufc when the Tumor is prefled with the Finger, nothing comes out but a clear and tranfparent Lympha. But that Name is not very proper for that Difeafe, fince the lacrymal Bag is defign'd to receive Tears, and contain them for fome Time, in order to convey them by degrees into the Nofe through the Channel of thd Nofe, which is only a Continuity of the Bag. And when the Tears cannot run into the Nofe, becaufe the Channel of the Nofe is obftruded, or for fome other Reafon, and when the Lympha mixes with them n that membranous Bag is forced to throw it felf eout of its natural Place, and to form a Hernia, In the fame manner as I have faid, that the Urine being detain'd in the Bladder diftends it, and occafions a Hernia of the Bladder, and not a Dropfy of the Bladder. Fot the Bladder being only defign'd to contain Water for a Time, it would be abfurd to call a Retention of Urine a Dropfy of the Bladder. MR. Arnaud admits of two Sorts of Fiftulas id general, a true one, and a fpurious one. He includes under the true one the different Kind, I have jufft now defcribed; and by the Fiflula lacrymalis, which he calls fpurious, he means a fmall Ulcer to be found fometimes at one or two Lines from the Interflice between the two Eye-lids, on the Side of the great Angle, and which has not its Origine, either in the lacrymal Bag, or in the Os anguis, but proceeds from a higher Place, as I fhall fhew by fome Inftances in the next Chapter. WHICH way foever the Abfccfs of the lacrymat Bag be formed, one may always forefee that this fmall Bag, being full of Pus, will comprefs the Channel of the Nofe, and prevent the Circulation of the Blood. z irl 339 A7 reat;fe of the in its Veffels, by compreffing its Veins, which make lefs Refifance than the Arteries; and that there will happen an Inflammation, whereby the Coats of that Channel will be brought fo near one another, that it will give no Paffage, either to the Pus, or to the Tears. Therefore, in a FflJula Lacrymalis, the Noftril will be very dry on the Side of the affected Part. THE Pus difcharging it felf continually towards the Channel of the Nofe, and its Salts corroding it continually, they will produce in it fome, proud Flefh, which will wholly flop the Paffage, and occafion again a Drinefs in the Nofiril. THE Pus being very copious in the lacrymal Bag, will iffue out of it, as the Blood fupplies it with frefh 'Pw, or by the different Compreffions that may be made in it. But becaufe its Paffage will be flopped on the Side of the Nofe, it can only come out through the lacrymal Points: Therefore, in that Cafe the Eye will be full of Tears, and fome Pus will come out through there laft Channels. AN D becaufe the Pus coming out through the lacrymal Points, falls upon a fmall Caruncula, which lies between thofe two fmall Apertures; one may very well guefs, it will frequently be covered with it all over; and that Pus corroding it by its Salts, as well as the lacrymal Points, it will irritate, and bring an Inflammation upon them. Therefore, in a Fifula Lacrymalis, the lacrymal Points and the fmall Caruncula will be inflamed, and frequently ulcerated. A-N D becaufe the Tears and the purulent Matters cannot meet with Refiftance on the Side of the Nofe, without being forced to gather in a greater Quantity, both in the lacrymal Bag, and about the Eye; the lacrymal Bag difcharging it feif, as I have already Operatloi of S t R G R Y. 339 already faid, through the lacrymal Points, will fill encreafe that fuperabundant Quantity. And the Lacrymal Gland, which lies in the upper Part of the Orbit, fupplying frill the Eye with Tears, even in greater Plenty, by reafon of the Irritations of the adjacent Parts, thofe Tears will be forced to come out of the Eye, and to run down the Cheek, nay they will fometimes be attended with Pus, which is a diftindive Sign of that kind of thedding of Tears. BUT the Pus iffuing out continually through the lacrymal Points, will at length corrode them to fuch a Degree, that they will be filled with a fpungy Flefh, whereby the Iflhe of the Pus through thofe finall Apertures will be prevented. It will therefore happen fometimes that the Fif/ula Lacrjmalis will have no Entrance, which may be further explained by other Proofs. THE ~Pus cannot be flopped on all Sides in the lacrymal Bag, without corroding it, and making its Way through that Part, which makes the leaft ReJiflance: And the Skin that covers the lacrymal Bag making lefs Refiftance, will more eafily yield to the Quantity of Matter, which will encreafe more and more; and the Salts corroding its Texture, will at length make it fo thin, that they will go through itý and difcover to us a fmall Ulcer, not far from the Interftice between the two Eye-lids, and thro' which the Pus of the lacrymal Bag will be voided in Part: This will chiefly happen, when the lacrymal Points are flopped. L A STL Y, the purulent Matter corroding ftill the lacrymal Bag, 'tis plain it will be wholly deiftroyed in time; and becaufe it touches immediately the Os unguis, Part of the Osplanum, and of the upper Angle of the maxillary Bone, it follows that the Puis, Z when 340 A Theat/2' of the when it touches thofce Bones, will corrode and rot them. But becaufe its greateft Impreflionii will be mnade upon the Os unguis, and becaufe that Bone is the thinneft, and it has been lately obferved that it is not covered with the Perioe/urm, it will be pierced firft of all, the fmall Cells lying behind will be rotted by it, and at laft the 'Pits will open its Paffage into the Nofe. And if the lacrymal Points are then open, the Tears and the purulent Matter taking their Courfe throngh the Nofe, the fhcdding of Tears will ceafe. THE Prognoftick of all F1flulazs in general is bad, efpecially of thofe, which are continually imbibed with fome Serofities, fuch as the FJflula Lacrymalih But the Prognoflick of the latter is more or lefs complicated wvith the Accidcnts above mentioned. IF the Tumor being prefled, nothing but a clear and limpid Water comes out through the lacrymal Points, 'tis a Sign that the lacrymal Bag is only dilated; this we have called its Hernia; and it may be remedied by Injcaions and by Compreflion, as I flhall fhew hereafter. IF the Tumor being preffed, the Water comes out Rill perfectly clear, and fome Pus comes out next, there is no reafon yet to believe any Corruption; and the Injelions and the Compreflion will ftill be fufficient for that Cure. But if the Tumor being compreffed, nothing but Tus comes out, it is not improper to enquire whether the Fiflula has been in that Condition a long time; for if it be very old, there is good reafon to fufped that the Os zunguis is rotten; and in that Cafe the Operation, tho' frequently ineffedual, is the only Remedy. If the Fiflula is recent, the utmofi that can be fufpeded, is Corruption in the lacrymal Bag; and then Injedions and the Cormpreiflion Operations of S u R G E R Y. 341 prefflion may be tried, without forgetting general Remedies, as I am going to explain. THOSE Fi/ulas, that are occafion'd by the Obftrudion of the lacrymal Points, are fomctimes incurable. All thofe; for inftance, that fucceed the Small-Pox, are incurable. WHEN the Tumor being prefled, no Pus comes out through the great Angle, but on the contrary through the Nofe, 'tis a plain Sign that the Paflage of the Channel of the Nofe is free and confcquently the Caufe of that Illncfs muft be looked for elfcwhere. WHEN a Patient has been troubled with that Difcafe for a long time, and the Nofiril is at firft very dry, as I have already faid; Laftly, when the Pus, having pierced the Os unguis, and rotted the fmall bony Lamine, that are behind, to open its Paffage through the Nofe; I fay, when the Pus has, as it were, overflowed the finall Windings to be found in it, 'tis plain that corrofive Matter has done a great deal of Mifchief, which cannot be repair'd by the Operation, even though Fire was applied to the Part; from whence it follows, that this Difeafe is incurable. HOWEVER, becaufe the Progrefs of the Fiftula is not exaftly known; becaufe it cannot be affirmed that 'tis impoffible for Surgery to cure it: and becaufe by curing the Ulcer lying in the lacrymal Bag, if it can be done, one may prevent the Ophthalmy and the Pain, which always attends it, fince 'tis certain that th. Operation is the moft cffeatual Remedy for a Fifula lacryma/is, it may be attempted by the Surgeon, who muft reprefent to the Patient and his Friends the Danger of the Difeafe, and the Improbability of a good Succefs to cure it radically. NAY, it is the Surgeon's Duty to call for Advice in Z 3 " fuch 3 4 A Treatife of the fuch Cafes, in order to fecure his Reputation againft common Reports, that are only grounded upon Ignorance and Rafhnefs. THOSE Fitfulas, in which there has been a Caries, and upon which an Operation has been performed already, are incurable. BEFORE I make an end of the prognoftick Signs, it is not improper to enquire into the Patient's Conflitution 5 whether he be lean and emaciated; whether he has had any Wounds, or had Impoflumations before that Difeafe, that were cured with great Difficulty; whether his Parents were affeted with the King's Evil, the Scurvy, or the venereal Difeafe; or whether he himfelf be free from them: For the Surgeon muff dirge his Prognofticks by all thofe Comr plications. CHA P. XXXVIII. Of the Operation of the Fiftula Lacrymalis. T HE Preparation ought to be different, and longer or fhorter, according to the different Caufes and Complications of the Fiflula Lacrymalis, THE Patient muff be always blooded once or twice, and gently purged before the Operation. If the Acrimony and Saltnefs of the Tears, and confequently of the Blood, are thought to be the Caufe of that Difeafe, the Preparation muft be very long, and the Defign of it muft be to fweeten the Blood, and intangle its Salts, Among the Remedies proper for it, Milk is one of the bef: Care muft be taken to purge the Patient frequently, and to give him now and then ibforbing Opiates. Operations of S u R G E R Y. 343 IF the Surgeon has any Sufpicion of a fcrophulous, fcorbutick or venereal Ferment, he muft continue for a cogfiderable time all the Remedies proper for thofe Difeafes. HE is to prefcribe to the Patient, in the time of the Preparation and Cure, a firid Diet; for a great Benefit may be expeaed from Sobriety and wholefome Food. We know by Experience that a bad Diet has frequently occafion'd the Death of the Patients, or very great Accidents. WHEN the Tumor is preffed, if nothing but Serum comes out, or fome Serum, and then Pus, the Cure may be hoped for, either by Injeftions, or by Compreffion. IN order to make an Inje&ion into the lower lacrymal Point, the Surgeon draws the Eye-lid to lay it bare, and introduces the End of a very fmall Syringe into that little Hole. Afterwards he raifes a little the Hand that holds the Syringe, and makes fome fmall Motions to look for the lacrymal Bag,,coming as near the Orifice of the Nofe as is poffible. IN order to make an Inje&ion into the upper lacrymal Point, the Surgeon removes back the upper Eye-lid, to difcover alfo that little Hole; and when the End of the Syringe is introduced into it, he raifes his Hand gently, and makes fome fmall Motions to look for the nazal Bag, and, as I have already faid, comes as near the Orifice of the Nofe as he can. THE Liquors to be ufed for thefe Inje&ions, ought to be very clear and mild: Nothing that is cauftick, ought to be injeaed and if the Surgeon perceives that the Injetion occafions any the leaff Irritation, Pain, or Inflammation, he muft give it over. 2; 4 To 344 A Treat e~ of the To cure thofe two Difcafc; by Compreffion, which is but a palliative Cure for the moft part, though it fometimes proves a radical Cure, viz. when the 'P has not yet rotted the Bag, as I have faid, fpeaking of the Prognoftick; when its Dilatation is not very great; when thofe Difeafes are new, and the Bones arc not at all rotten; I fay, the Surgeon muft from time to time prefs the Tumor with his Finger to let out the 'Pus, and then ufe the Compreflion immediately: It has frequently proved fucccfsful. Mr. Arnaud cured many Patients after that manner. Mr. Arnaud propoles for that Compreflion a Steel Bandage, which is applied upon the Crown of the Head, and a Branch pafling over the Coronal, falls upon the Tumor, which the Patient himfclf can comprefs as much as he pleafes, with the Help of a fmall Spring, that lies in the Hinge of that Branch. HERE follows Mr. -Dionts's Method for that Compreflion. After he has laid upon theTumor four or five graduated Compreffes, rifing above the Nofe, he faftcns them with a fmall circular Lift, which prefling the Compreffes againft the fmall Bag, prevents the further gathering of the Matter, dries up its Fountain, and enables the Part to recover its Spring, provided that Bandage be ufed for fome Months. I believe, that if a Piece of brown wet Paper, and chewed, xNas laid on, before the Compreffes, it would 4xadly comprefs the Bag in all its Parts, and as it dries, be fo well adapted to the Figure of the Part, that the Compreflion wOuld always be the fame, and iuchimore exa&t. I imitate therein Mr. Petits Method, who lays outwardly fome Lint upon the Sinus's, to comprefs them in all their Parts, as I have faid, when difcourling of the Sutures. **, Operatios of SURGER Y. 3 4 I muft further obferve, that the Comprcffes ought to be notch'd, that the Eye may have a full Liberty, without being offended by the Compreflion. I fhould prefer the Monoculus, which I fhall defcribe" hereafter, to the circular Bandage of Mr. )ionist becaufe it compreffes better, and is not fo apt to be difplaced and difordered. WHEN thofe Methods of Operating have not all the Succefs that was expeCed from them, and the Patient is not contented with a palliative Cure; or when the Ftflula is attended with Complications, that require other Remedies, the Surgeon muft proceed to the Operation. He fhall put it off for fome Days, if there is a great Inflammation in the great Angle of the Eye, that the Anodyns and foftening Remedies may have Time enough to mitigate the Pain. LET us fuppofe for the Operation a Fiftula with a Callofity, carious in the Os unguis; in the Cells that are behind, in a Part of the Os planum, and in the upper Angle of the maxillary Bone; which is one of the moft complicated Fiftulas. In order to perform the Operation proper for fuch a FtJiula, the Patient muff fit upon a Chair his Head muft lean againft the Back of it, and be fupported by a Servant's Hands croffed upon his Forehead. Mr. Arnaud, before he begins that Operation, ufes a Comprefs dipt in Role or Plantain-water, with which he covers the found Eye, and faftens it with a Handkerchief folded in the Shape of a Triangle, &c. that the Patient may not fee the Infiruments and the Operation. He covers the tick Eye with a fmall filver Spoon, which is of great ufe upon two Accounts; for it has the fame Effed as the Comprefs upon the found Eye; and befides it ftrerches the Skin, and draws it a little towards the fmall Anglet but in fuch 346 A Treat;fe of the fuch a Manner that it does not change its Situation; for the Operation would prove ineffetual, when the Skin refumed its natural Situation. Mr. Petit does not ufe that Spoon, but he bids a Servant lay his fore and middle-Finger near the fmall Angle of the Eye, in order to draw the Skin, and confequently the two Eye-lids, towards the Ear in a parallel Line. AFTERWARDS, the Surgeon muft bend the Skin above the Tumor, according to its Length, laying the middle-Fngcr towards the Root of the Eye-brow, a little above the angular internal Apophyfis of the Coronal, and the Thumb near the middle of the Nofe, and a little above.and near the Dua of the maxillary Bone, which opens a Paflage to the middle Branch of the fifth Pair. The Surgeon, by keeping thofe two Fingers afunder, will ftretch and brace the Skin, and by that means will eafily cut it. THE Incifion, that is now to be made, is different, according to the antient Authors and the Surgeons of our Time. Authors, and efpecially a modern one, advife us to begin it overagainft the Inter, Rice between the two Eye-brows, and even a little lower, in order to preferve the Tendon of the orbicular Mufcle, the Seaion whereof, fay they, would occafion a Laceration of the Eye-lids. But the Surgeons of our Time, who are better Anatomifts than their Predeceffors, have found out that the Orbicularis is faftened to the whole Circumference of the Orbit; and Mr. Arnaudhas obferved from his own Experience, that the Setion of one of its Parts could not relax it. ONE may add to that Argument grounded upon the Stru&ure of the Part, that if the upper Angle of the Inciftoa began a little below the Conjundion of thq Operations f S U R G R Y. 347 the two Eye-lids, it would exadly be in that Place which ought to be moft dilated, and that the Lips of a Wound, of a Figure almoft longitudinal, cannot be fo well kept afunder in its Angle, as towards the Middle of it. MR. Arnaud and Mr. Petit advife us to make that Incifion of a Figure half fpherical, the convex Part of which will be towards the Noce, and the Concave towards the Eye. The upper Angle of that Incifion will begin at the Root of the Nofe, I mean, upon the angular internal Apophyfis of the Coronal, and will be conveyed in a femicircular Figure upon the Side of the Nofe, or pafling over the Tumor, it will end upon the maxillary Bone almoft at the Original of the Obliquwsparvus, The Surgeon muft take care that the Middle of that Incifion, which ought to be an Inch long, be about three Lines diftant from the Conjuntion of the Eye-lids; for the Laceration of the Eye-lids is occafioned by the Dcftrudion of that Conjuntion, and not by the Setion of the Tendon of the Orbicularis, as we fhall fee from the following Inftances. MR. Arnaud had under his Care a Patient troubled with a Ffula Lacrymalis. He made the Incifion according to the Method defcribed by Authors; and confequently he avoided the Tendon of the Orbicularis, and yet the Eye remained lacerated. Inquiring into the Caufes of that Deformity, he obfcrved that he had made the Incifion according to the Rules prefcribed by Authors, and too near the Conjundion of the Eye-lids 5 fo that the Suppuration, which happened in the remaining Part of the Skin, whereby the Eye-lids were united, having by the Dilatation caufed, and the Heat of the Funnel, entirely defiroyed it, caufed a Laceration. THE 348 A 7'eat/fe of t he THE fame Surgeon, performing that Operation a fecond time, took, in order to make thc Incifion, all the Dimenfions I have juft now prefcribed. He worked under the Skin, and wholly cut the Tendon of the Orbicularis, taking Care to preferve the Skin, and make his propping Point upon the Bones of the Nofe; and the Patient was cur'd without any Deformity. From whence it may be inferred that the Operator need not be afraid of cutting the Tend'on of the Orbicularis; but he ought by all Means to avoid cutting the Conjundtion of the Eye-lids. Let us rcfuLme our Difcourfe. THAT Method of operating is of great Ufe upon two Accounts. As to the'firft Ufe, the Surgeon muff know that a Fifula Lac:yma/is is fometimes occafioned by fobme Defcas which proceed neither from the Bag, nor from the lacrymal Points, but from a Rottenncis of the upper'Bones, fuch as the Os planum, or the Angular Apopfhyfes of the Coronal; fo that 'tis impoflible to cure thofe Difeafes, unlefs the Remedy be applied upon the Part affeated it felf. This the Surgeon may do, if he begins the Incifion about thofe Parts, as I have faid, becaufe when he difcovers the Fountain, he may dry it up. THE fecond Ufe arifing from that Method, is that the Surgeon may dilate the Wound in the Fiflula, fince it lies in the Middle of the Incifion.. THE Infirunments to make that Opening are different according to the Operators. We are told in Books, that it ought to be made with a flrait Bif/ouri, faftened to the Handle with a Fillet. Mr. ArInaud ufes his fmall Poniard; but that able Praftitioner, having obfcrved that the Blade grew blunt upon the Bones, before the Operation was finifhed, has contrived an Infirument, the End of which is made like a Sat1!a. Mr. 'Petit ufcs a very fmall Bi/louri fomeI Operations of S u R 0E R Y. 349 fomewhat crooked: He drives it in, as far as the Bone, in the Place above mentioned, and continues to open the Part as I have faid. Before he quits his Biftcuri, he enlarges the Wound under the Skin, to cut the Tendon of the Orbicularis, which is hurtful in the Operation. Afterwards he ufes a Fleam or a Myrtle Leaf, which he carries up and down fcveral times in the Wound, in order to dilate it. He takes again the Bitfouri, to make an End of cutting what might have been left the firil time, and conveys it into the nazal Duft, holding it like a writing Pen, the Edge being turned towards the Infide of the Hand: There he cuts a fmall kind of Bridle lying upon the Edge of that Dut, and formed by a Folding of the fPeriofleum. And becaufe in fuch a Cafe the Obliquus parvus is divelted of Fat, it ought to be cut; "for it is troublcfome to the Operator. IF the Surgeon, when he makes that Incilon, perceives that the angular Vein is varicous, he muft cut it; if not, he may preferve it. He muff have many fmall Pieces of Linnen to wipe the Blood, as it comes out; for a Surgeon ought to perform his 0 -perations, as dry as poflible. IF he has opened the A ngular Vin, he muft make a Compreflion towards the Angle of the Coronal, becaufe it proceeds from thence. 'But if the Hemorrhage proceeds from an Artery, the Compreflion ought to be made upon the maxillary Bone in the lower Part -of the Orbit, becaufe the Artery, that goes to the great Angle, paflks that Way. Afterwards, the Surgeon drefles the Wound with Dozels, the firft of which muff be tied, till the next Day when he makes an End of the Operation. TH E Comprefi on and the Dozcls having dilated the Wound very much, and ftopped the Hemorrhage, the 3 50 A eatife of the theBones appear bare the next Day, and the Surgeori fees thofe Parts that are damag'd by the Caries; THE RE are feveral Ways of deftroying that Caries; fome are for applying Caufficks, fuch as corrofive Powders, ftiptick Waters, d&c. Others are for taking it off altogether. The latter, whofe Opinion feems to be more reafonable, teach us two Ways of performing that Operaiion, each of which is approved by fome. The firft Method confifts in piercing the Os unguis with Fire. The Favourers of that Operation acknowledge that it is the moft perplexing and the moft troublefome, but the fafeft, becaufe, fay they, Fire divides the Bone into faich fmall Parts, that it exfoliates intirely. Befides, the Efear, which happens in the adjacent Parts thro' the Adion of the potential Cautery, leaves, by falling off, a away for the Conveyance of the Tears into the Nofe; which does not happen, when the Bone is removed without the Help of Fire, for a new Way muft be made for the Tears to pafs into the Nofe, fince the lacrymal Bag is deftroyed, otherwife there would ftill remain a Weeping. THE Favourers of the fccond Method, which confifts in piercing the Os unguis with a Stilct, or fome other Infirument, fay, it is more eafy, more fpeedy, lefs perplexing, and as fafe as the other, fince they can break the whole Bone, take the Splinters out of it, and keep in the Nofe a Spunge or a Tent, as well as in the other Method of operating. IF the potential Cautery be refolved upon, Mr. Arnaud proceeds in the following Manner. Having covered the found Eye of the Patient, and placed him upon a Chair, as I have already faid, he calls for a Bafon full of Water, which will be of great Ufe, as we fhlall fee hereafter. Aftcrwards, he conveys a Stilecr Operations of SuRGER. 351 Stilet upon the Os unguis, laying it from the Temple towards the Nofe, to avoid the maxillary Sinus; which being done, he conveys, with the help cf the Stilet, a fmall Funnel with a Handle to it, the End of which is cut floping, that it may be adapted to the inclined Plane of the Os unguis. The Funnel, by that Means, leaning faft upon the Bone, the 0 -perator takes the largeft Cautery, which ought to be red hot, and conveys it upon the Bone with the help of the Channel of the Funnel, taking care not to bear too hard, (for the Os unguis is not thick,) but to move it gently, to make way for the Funnel, THE Cautery is to be turned toward the Nofe, to avoid piercing the maxillary Sinus, whereby the Separation of the Snot would be prevented, and the Operation would prove ineffet&ual. Befides, the Cautery muff not remain too long in the Funnel; for the latter growing hot burns the Skin, which re-unites the Eye-lids: And this is the true Caufe of the Laceration. The Surgeon muff therefore remove the Cautery and the Funnel, to put them both into the Bafon full of Water. AFTERWARDS, he wipes the Funnel, and lays it again on the Bone; which may be done without the help of the Stilet, becaufe the firft Cautery has already opened the Way. The Operator cauterizes the Bone again with a fmaller Cautery, and perceives that it is pierced by the Blood and Smoak coming out through the Nofe. I F the Surgeon deigns to pierce the Os unguis without applying Fire, he muff ufe different Inftruments. Mr. Arnaud pierces it with a grooved Probe, open at the End, and fays, it muft always be convey~ ed from the Temple towards the Nofe, and not toward# 3 Z A Treattfe of the wards the Cheek, for fear of offending the maxillary Sinus; which has happened to able Surgeons. MR. Petit ufes his Fleam, or a myrtle Leaf, with which he thrufts the Os unguis towards the Nofe to pierce it; which is no very difficult thing, becaufe that Bone is very thin. Afterwards, he moves his Hand up and down to the Right and to the Left, to break it and wear it entirely away, One may perceive, it is well pierced by the Blood, that comes out through the Nofe. THE Surgeon lays that Inftrument afide, and takes Pincers to remove the bony Pieces, as much as he can; and becaufe in the following Dreflings fome of thofe Pieces come off, he is to attend carefully during the four or five firft Days to take them out. HAVING mentioned all the different Operations, I proceed to the Drefling. Mr. Arnaud lays at firft a Piece of prepared Spunge, as big as the grooved Probe, pretty long, and tied at one End: He conveys it as far as the Nofe, and leaves it there two Days. Mr. Petit ufes a very fmall Dozel, or a Roller of Linnen, tied in the Middle with a double Thread: He thrufts it as much as he can with his Fleam into the fmall Hole, he has made in the Os unguis. Upon that Dozel he lays another of Lint, and at laft feren or eight, which he fills up and dilates the Wound very much; taking Care always to keep the fore and middle Fingers upon the Dozels, to take them off but one after another, in order to put in new ones, to thruft them always towards the Bone of the Nofe, and to keep the Eye free. Upon thofe Dozels he lays a fmall Comprets notched on the Side of the Eye, and thick enough, and then another fomewhat larger, a third, a fourth, and fo on, till they rife above the Angle of the Coronal, Operaitons of SURER Y. 33 tonal, and above the Nofe, that the Bandage may only ftraiten the Compreffes, and have its propping Point dir.ely upon the affeded Part. The Surgeon covers that Dreffing with two large fquare Compreffes, and fupports the whole with the Bandage called the fingle Eye, which I am going to d"efribe, or by the Monoculus, of which I fhall give a Dcfcription, when I come to difcourfe of Bandages. Of the Bandage called the fingoic-Eye. THIs Bandage is made with a rolled Band with one Head, eighteen Feet long, and two Inches broad. The Surgeon applies the End of the Band to the Nape: He bids a Servant hold it there; or ties it to the Cap. He conveys the Globe of the Band under the Os male, which lies on the Side of the affeaed Part, to afcend obliquely to the great Angle of the Eye; taking care that the Middle of the Band lean upon the Compreffes, that the Compreflion may be more exat and tronger. Afterwards, he conveys the Head of the Band to the Nape, paffing obliquely over the upper Part of the Parietal, which lies on thed Side oppofite to the Illnefs. He makes agaira two Turnings like the foregoing, taking care hdowever that the Band be flanting in its Afcent, from under the Os makl to the Root of the Nofo, and that in their Defcent they may be from the Roo of the Nofe to the Top. The Middle of the Band, in there two Turnings, as well as in the firft, iuit pafs through the Middle of the great Angle of the Eye, and upon the Compreffes. Afterwards, the Surgeon turns thc remaining Part of the Band about the Head. THAT Bandage is called the Ji'ngle Eye, becaiufe it Covers but one Eye. It may ferve to contain fome Sa, -edic& 354 A Tieat'fe of the Medicaments, and for the Operations to be performed in the great Corner of the Eye. I have often feen Mr. Petit make it for a Fifula:Lwrymalis. That Surgeon does not convey at firft the End of the Band to the Nape; but bids a Servant hold it upon the Middle of the Clavicula; and when the Bandage is made, he revcrfcs that End of the Band, drawing it a little hard, to tie it to the Nape: By which means it is fafter fill. THE Cure of that Difeafe confifts, fifft, in blooding the Patient two Hours after the Operation, and then in dreffing him every Day, much in the fame Manner. And becaufe there grows a kind of granulous Flefh in the Interval of the Unequalities of the broken Bone, they ought to be confumcd with the Lapis infernalis, and likewife thofe, that arife upon the Bone, which are only proud Flefh. Wherefore we are for making always a great Compreflion, in order to prevent their Growth and when the Bone is exfoliated; (which may be known by the Flefh which arifes from the Bone it felf, and adheres ftrongly to it, which is not of fuch a lively Red, and which appears to be folid, when touched with the Stilet, and occafions no Pain; ) then, I fay, this Flefh may be allowed to grow. But, that it may be folid and good, and may not grow too faft, the Surgeon is to rub it over every Day with the Laps infernalis, and to leffen the Compreflion by Degrees. THE Patient muff be regular in his Diet; and if the Suppuration appears to be plentiful, the Surgeon ought to doubt of the Cure, and believe that the Mafs of Blood is corrupt. Wherefore he muft repeat Phlebotom-y, purge the Patient from time to tinie, apply a potential Cautery to the Nape, or upon the Tendon of the dcltoid Mufclc. It is a powerful Operat;ons of SUR GERY. 3f tiful Remedy, authorifed in that Cafe by the Pradice of Fa4ri Ijildanus, oneof the greateft Surgeons we have had, arid who has left us a great many fine Obfcrvations. Nay, the Cautery, or the Seton ought to remain for fome Months after the perfed Cure of the iflula; and when it is to be cicatrized, the Patient mufi be purged feveral times. Veficatory Plaiffers may alfo be applied behind the Ears, or be. tween the Shoulders, and ihould be made to run as much as pofliblc. BECAUSE the Blood is diffolved and ferous, and becaufe it keeps up the Ulcer by a plentiful Suppuration, and frequently makes thofe Difeafes incurable, s I have often obferved, though the ableft Surgeons, whom I have fo often quoted in this Treatife, had performed the Operations, and ufed the potential Cautery, or.Inftrumenrs to pierce the Bone; X fay, the Surgeon muft defiroy the Salts, which divide the Blood, abforb the acrimonius Serofities that overflow it, and reflore its original Texture. This is what makcS it requifite to prefribe convenient, and frequent IPurgatives, Viper and Lobfter Broths, fudorifick Ptifans, Milk mixed with a Decotion of Salfa Parilla, abforbing Opiats, and frequent Purgations during -the Courfe of all thefe Remedies. I F the Surgeon has had the good Fortune to remove the Caries, to dry up the Sourfe of the 'Pzs, and to cicatrize the Wound, it may be faid, the worft Accidents of the Difeafe are over: But whether the Operation be performed with or without Fire, the Weeping continues fill, tho" thofe who approve the adual Cautery, fay that by their Method of operating, they open a new Way for the Tears. I could never apprehend how that new Way can be preferved, and give a free Paifrge to Tears thr9' Aaz2A 356 A 7Treatife of the the Nofe, fince it appears that the Wound fills up with firm and folid Flcfh (I fuppofe it to be in a fair Way of being cured,) and confequently there remains no Opening in it. Befides, the Tears cannot pals from the Cavity of the Orbit, into that pretended Way, unlefs the ConjunCtive were pierced abt moft in the Place where it adheres to the great Corner of the Eye, and the Tears ran out thro' its Orifice, to go from thence thro' the Hole of the Os unguis into the Nofc; for the lacrymal Bag being deftroyed in the Operation, the lacrymal Points are of no further Ufc. Now this was never done, and never taught. L AST T L, I have feen Fifjulas, which had been under the Cure of the ableft Surgeons: In fome of them tlhofe Surgeons ufed the aaual Cautery, and in others mere Inffruments, without Fire; in fome they could not dry up the Source of the purulent Matter, nor cure the Abfcefs; in others, which feemed to be better cured, the Weeping continued ftill. We ought therefore to concludc from thofe Experiments, either that thofe Difcafes cannot be better cured, or that we are frill ignorant of the true Method of doing it. MR. Petit iaS lately performed that Operation in a very fingular Manner, and with a wonderful Succefs. Inftead' of attempting to open a new Way for the Tears, (which never fucceed,) he fancied that if the Way, which Nature has given them, could be preferved, thofe Difeafes might be cured without. And indeed, I faw him pafs a twifted Wax-candle through the lacrymal Bag, and the nazal Dud, which are the true Paffhges for the Tears, and make it come out through the Nofe. He kept that twifted Waxcandle in thofe Places, 'till' he pcrceived by the Mattcr, Operations of SU tG ER Y. 357 ter, that the Dud was very found. The Woman, upon whom Jifaw that noble Experiment made, was cured withoqt any Wecping. IF that Dfeafe has hitherto given fo much Trouble to Surgeons, what Acknowledgment ought they not to exprefs to the learned Praflitioncr, who has lately facilitated and afcertained the Cure of it? THAT Operation is frequently performed without Neccfity; and therefore it is the Part of a prudent Surgeon carefully to examine the Difcafe, and all its Circumftances, in order to avoid performing the whole Operation of the FiJfula Lacrymalis, when a mere Inciflon can cure it, as it will appear by the following Obfervations. The frJfl OBSERVATION. M R. Arnaud had under his Cure a Patient troubled with a Tumor in the great Angcle of the Eye, which extended chicfly upon the upper Part of the Bones of the Nofe, and upon the rifing of the Coronal, which receives thofe Bones. He made a longitudinal Incifion, which took in a Finger's Breadth of the Coronal, and a Finger's Breadth of the Bones of the Nofe; fo that after the Incifion, he perceived that the Apophfis of the Coronal was carious, which occaftoned the Tumor; and with the Help of Remedies proper for that Caries, he cured his Patient. The fecond OBSERVATION. TH E fame Surgeon owns that he performed the whole Operation upon a Patient, who feemed to have a true Fi/hula; and after he had pratified all the Rules of his Art for the Cure, he was furprifed Aa3 to 358 A. 7teatife of the to fee his Labour without any Succefs. Having endeavoured to find out what prevented the Cure, he perceived a Serofity, which proceeded fqm a Part above it. This moved him to look for the Obftacle to the Cure, and he found that the Original of the Abfcefs was in the Os planum. He applied upon it a fmall Dozel dipt in fhiptick Water, and then fqueezed fufficiently, and the rcft, as ufually. The Patiect was perfedly cured. The thirdOBsERVATIoN. LASTLY, Mr. Arnaud faw a Patient, who had two fmnall Ulcers; one over againft the Conjuntion of the Eye-lids, in the great Angle of the Eye; and the other, a little higher. He Icfearched the lower Hole with a Stilet, and perceived it did not reach lower. On the contrary, there was in the other Hole a finall Sinus, proceeding from the Rifing of the Coronal, which fupports the Bones of the Nofe. Mr. JfinJlow calls it the nazal Apfophyjis. The better to fecure that Way, he put into it a Piece of a prepared Spunge, which enabled him to introduce the next Day a grooved Probe, and with the Help of that Infirument he conveyed a Branch of the Sciffars, and opened it. Aftcrwards, he made a Dilatation at the Root of the Nofe with his Finger, where he perceived a Vacuity, and the Bone carious. He applied the adual Cautery; and there came out, by the Exfoliation, a fmall Bone of the Bigoefs of Lentild. Tj>e Patient was perfedly cured. CHAP. XXXIX. Operations of SUR GER Y. 359 Ott) ~ U i, 4t CHA P. XXXIX. Of the f1oruinds of the Head, and the Fractures of the Skull, in relausion to the 7;epan. W E divide the Wounds of the Head, as well as thofe of other Parts, into fimnple and complicated Wounds. SIMPLE Wounds are thofe, that are attended with no Accident, and only require a fpccdy Reunion, in order to be cured. On the contrary, complicated Wounds do not require Afch a fpeedy Cure, and muft be differently treated, according to their different Complications. THE Wounds of the Head as well as thofe of 0 -thcr Parts, are generally occafioned by pointed, lharp, or bruifing Infirumcnts; and thofe Sorts of Arms include whatever can pierce, divide, break, rear, fplit, bruife, deprefs, &c. PRICK1NGS are very dangerous, when they penetrate under thofe Places where there are hard Bodies: This I flall obferve, when I come to difcourfe of the Panaris, where I Ihall fihew that the Pus to be found under the Nail, though in the firft Sort of 5Panaris, which is generally very fimnple, requires the Nail to be cut in that Part where the Matter lies, to evacuate it, and put in the room of it fonme Lint or Linnen, for fear the Unequalities of the Nail flould offend the quick Flefh, which is very fenfible;3 and without fuch a Precaution, the Dif cafe, though very fimple in it felf, happens frequently to be compic leed. Aa 4 THE 3 o A Treat;/e of the TiE fame thing happens to Horfes, that have been pricked with a Nail, or fome other Inftrument 3 for the Pus gathering between the Flefh and the Hoof, the Horfe remains lame, and is not to be cured, unlefs that Part of the Hoof which covers the Abfccfs, be taken off. The pricking of the Teguments of the Tendons will alfo afford us remarkable Inflances of what I fay. THE Wounds occafioned by cutting and bruifing Inifruments in the Skin of the Head, and of the Tegument formed by the frontal and occipital Mufcles, have often the fame Fate, efpecially when the internal Wound is not fo large as the external, and there happens a kind of Confitriion, Dreadful Accidents will happen then, and they are attended with fad Confequences, unlefs their Caufe be fpeedily deftroyed 5 or when the Patient is under the Care of a Surgeon, who fancies he dreffes a Wound according to the Rules of Art, when he heaps up, in a Divifion, three or four Dozels one upon another. I faw at my Father's a Wound, whereby this laft Inftance will be confirmed. A Woman, who lived about four Leagues fromn Jtre, was wounded in the Head by a Ladder of one of her Neighbours: The Wound was an Inch long 5 and the Bone was not bare. The Surgeon of the Village drcifed that Woman, and the next Day carried her to Town, in order to be vifited by my Father, who was the King's Surgeon, that fhe might know of him the Nature of her Wound. That Wound feeming to be very fimple, the Report proved no difficult.thing,;nd the Fees for the Dreffing, and Medicaments were taxed at a moderate Price. The Patient went home-with her Surgeon, who continued to drefs 4c; and three or fotir Days after, th;rc happened perati;ons of SURGERY. in that Wound an Inflammation, which occafioned a Confiriaion in the Skin. That Accident was quick. ly attended wxvith a violent Fever: The Patient's Eyes grew red and fparkling: She was affeaed with convulfive Motions and a Delirium: She vomited, and voided fome Blood through the Nofe. The Surgeon being furprifed at thofe Accidents, faid that my Father had looked upon that Wound to be a fimple one, though it was very complicated; and that there was an abfolute Necefity to trepan the Woman. MY Father was fent for: He went to the Village, whither I attended him. We took off the Drefling, and removing the Plailfer, I drew three or four Dozels, which fluck to the Middle of it: From whence I inferred, that Nature drove away a Heap of Dozels, which made her uneafy. I dreffkd the Wound with a Plaget dipt in warm Wine, having no other Medicament; and three Hours after, we were told that the Woman was free from all the Accidents, which had moved the Surgeon to think of trepanning her. In a Week's time, ihe came to thank my Father, and ihe was perfealy cured. T o give a further Account of the Accidents, that happen to the Wounds of the Head, and of their Remedies, I muff obferve that fometimes Blows, Falls, &c. make a Divifion to the very Bone, and that it is frequently attended with an Inflammation, or an Eryfpelts all over the Head. That Inflammation is fometimnies occafioned by the Conftriaion of the Skin, as I have already faid; and fometimes it is a Confequence of the Lefion of the 'Pericranium; for infiance, when the Tericranium has undergone a Contufion; or when its Opening does not correfpond With that of the hairy Skin that covers it. THE 36z A Treatie of the THE Remedies of thofe two Parts being different it is highly important not to confound their diagnoflick Signs, for fear of ufing Remedies for the hairy Skin, when the RPericranium is affcded. There is a certain Sign to know which of thofe two Parts is affected: It confifts in examining, whether the Ears be diftended and inflamed, or not. If they are affeccted with an Inflammation and Eryfipelas, as well as the reft of the Head, there is ground to believe that the Inflammation lies on the Skin, which is the common Tegument of all the Parts of the Head. But if the Ears appear to be in their natural State, one may boldly affirm that the Eryfipelaf and Inflammation affeft the Pericranium, fince it is well known that Membrane does not cover the Ears. IN the former Cafe the Remedies are the fame as for an Eryfipelas of the other Parts. On the contrary, in the latter Cafe, the beft Remedy is to open the tPericranium, if it be bruifed, or to enlarge its Opening, if it be not parallel to that of the Skin. THE Echaymofis, or Contufion, which happens on the Teguments, is of two Sorts: One by Infiltration, and the other by Effufion. The Contufion by Infiltration is cured with fpirituous and oily Remedies mlx'd together. The Contufion by Effufion is differently cured, according to the Caufe. If the Effufion be of the venal Blood, it may be refolved; on the contrary, if it be the arterial Blood, the Tu. mor muft be opened. Thofe two Sorts of Effuhfons are known; becaufe in the latter the Tumor is harder than in the former, the arterial Blood coagulating as foon as it is out of the Veffels. By a FraCture I mean a Wound in the Bone; and as I have defined a Wound in the foft Parts, a Solution of Continuity, or a Diyifion of the foft Parts of Operatios of SUR Gi RY. 363 of the human Body, recent, and fTill bloody, made by an external Caufe, that can cut, tear, prick, &c. I fay, that the Wound of a Bone is a Solution of Con. tinuity, or a Divifion of the bony Fibers, recent or old, and not bloody, occafioned by fome external Violence that can prick, cut, fplit, bruife, d&c. THE Antients have been pleafed to bellow great And puzzling Names upon the Fradures of the Skull: They are fuch Names as the moft experienced Surgeon could not repeat in a Fortnight, unlefs he made them his chief Study. I admit in general but three Sorts of Fra&ures: The firft fhall be known by the Name of Incifion, Mark, or Veftige 5 the fecond by the Name of Split; and the third by that of Contufion. THE firft Sort of Fradure, viz. the Incifion, Mark, or Veftige, is a Solution of Continuity in the Bone, made by a cutting Infirument, which reaches no farther than the Place ftruck by the Infirumcnt, and is always attended with a Wound in the Teguments. The Blows of that Kind being different, I fhall beftow different Names upon them, according to their Differences. FOR Inflance, a Blow with a cutting Infirumcnt, which makes a perpendicular Incifion in the Bone, attended with a Contufton, as it conflantly happens, is called a perpendicular Mark, or Incifion. WHEN the Blow is given obliquely ( I always fuppole with a cutting Infirument) and leaves a fmall Splinter which flicks to the Part, this I call an oblique Mark, or Incifion. WHEN the Blow is flanting, and carries off the whole Piece, that Sort of Frature is called a VefLige, or an horizontal Mark. WHEN 364 A Treattfe of the WHEN the Inftrument, which makes a perpendicular Incifion, continues its Effcat farther, it makes a Contufion in the external Part, and a Split in the Infide. The fame thing happens in the oblique Incifton, according to the Difference of the Blow; for if the Blow is not fo oblique, the Splinter will not be outward, but inward. THERE are alfo Marks upon the Skull, that go by the Name of the Inftrument that has wounded it, fuch as Keys, Ends of Guns, &c. The external Table of the Bone is generally feparated, in that Sort of Blows, according to the Figure of the Inftrument; and the internal is depreffed by a great Splinter. THE fecond Sort of Fratures, known by the Name of Split, is a Solution of Continuity in the Bone, and of a Solution of Contiguity, as I fhall fay hereafter, made by bruifing Inftruments, that can fplit, and bruife, which reaches beyond the Place ftruck by the Inftrument, and is fometimes without a Wound in the Teguments. THERE are alfo feveral Sorts of Splits according to their Differences. For Inftance, if the Split lies only in one Bone, and is fo finall, and thin, that it refembles a Hair, it is called a capillary Split. AUTHORS fay, that in order to difcover it, the Surgeon is fometimes obliged to lay fome Ink upon the Skull, and after he has wiped it, he perceives the Split by the Mark Which the Ink leaves in it. WFEN the Split is fufficiently vifible, and when the Pieces of the Bones remain in their natural Pofition, and are not at a Diftance from one another, it is called a Crack, or Split; Words very familiar and intclliible. Iv the Occipital is violently truck, and makes a Re-ftance, there appears a Separatioi between the tefiporal Operations of SVURGER Y. 365 poral Sutures, which we calla Counter-blow, or the Separation of the Suturcs; and the remaining Part of the Bone may be fplit, and then will occafion a Solution ofContinuity, or Contiguity, that will have different Names, according to the Differences of the Fradure. On the contrary, if the Temporals make a Refilfance, the Occipital muff neceffarily be fradured, or the Coronal, according to the mechanical Difpofition of the Pieces of the Skull, as I fhall fay hereafter; and the Frataure will alfo have the different Names juft now mentioned; whereby the Counter-blow is fill more diftinguifhed. THE Counter-blow, which I feem to maintain, is a thing very much controverted; and the greateft Part of the Moderns, excepting the learned Mr. 'Dionim, fay, Hippocrates admits that Frature without any Ground, and that his Divifion of it into feveral Kinds. is chimerical. I (hall exprefs a greater Refpeta for that great Man; and the Readers will acknowledge, as all learned Phyficians and Surgeons do, that nothing can be more exaa than the diagnoftick and prognoflick Signs he gives of each Difeafe, in his Aphorifws. How could he have attained to fuch an Exaane&l admired by all Phyficians, if he had not frequently ob. ferved thofe Signs in feveral Patients, and if he had not appointed one of his Scholars in the Houfe of cvery Patient, to take Notice of the different Alterations and Symptoms, in. order to know whether they agreed with Experience. 'TIs true the Moderns, who call the Counter-blowE a chimerical Thing, are Men of great Genius, and Learning, and well-skill'd in Natural Philofophy. But Surgcons, eminent for their Skill in Anatomy, and great Prafitioncrs, fhew by the mcchanical Struiurc of 3 66 A Teatie of the of the Bones of the Skull, and by feveral Infances, that the Counter-blow of all Kinds is poffible. BY that Accident the Ancients meant, firft, a Blow given to the external Table of one of the Bones of the Skull, without making any Frafturc in it, and the Violence of which aQs upon the internal Table, and breaks it. Secondl, a Fall, or a Blow given to the upper Part of a Bone without a Fratureoin the Place where the Blow was given, but in its lower Part, or that makes a Fradture in the upper and lower Part at the fane time. Thirdly, an external Violence ating with great Force upon a Bone without breaking it, but fracturing that which is contiguous. Fourthl, the laft Counter-blow, which is moft controverted, is that which paffes from one Part of the Head to the oppofite Part. For inftance, a violent Blow given to the hinder or foremoft Part of the Head, in fuch a Manner that the Part that is ftruck, makes a Refiftance, and the Frataure happens to be in the Coronal or the Occipital. To confute'thofe Opinions, the Moderns fay, in the firft place, that the internal Table of a Bone cannot be broken, whilft the external remains whole, by reafon of the fmall bony Lines which compofe the Diploe, and fo unite thofe two Tables, that they make but one Bone of equal Refiftancc. Secondly, they fay, that a Bone having no more bony Fibers in one place than in another, it cannot be fraaured in two Places by the famne Blow, and much lefs in that Part of the Bone, which is oppofite to the Blow; and if thofe Fratures have been feen, 'tis becaufe the Patient had received many Blows upon the fame Bono. To Operations of SURGr Y. 367 To anfwer the third Kind of Counter-blow, they make ufe of Sutures, as of an.intermediate Body, which breaks the Force of the Blow, and does not allow it to reach to the contiguous Bone. LaYfl4, they confitte the fourth Counter-blow of the Antients, much by the fame Argument and a.l ledge for an Inianice, that the Skull is only made up of a great many Pieces, that the Crack of one of thotv Pieces may not be communicated to any of the others. THE firfi Obje&io~n of the Moderns is anfwercd, by faying that if the '.Viloe was oflificd with both Tables in fuch a maniner, as to make but one Bone, without any Mark of 'Diploe, as I have often f.en; then the internal Table could not be broke without a Fra dure of the external; but becaufe that mechanical Difpofition is not the fame in all Skulls, and the CDiPloe is generally nothing elfc but a marrowy Subflance inclofcd in finall bony Cells, it follows that it cannot unite thofe two Tables in Thch a manner, but that the internal will be fra~Curcd, when the external, which happens to be more folid, refifts the Violence of the Blood. This is explained by learned Philofophers, who:alledge the Axiom, Nullum datur in natura vacuumr; and they fay, that a Man having received a Blow with a blunt Inflrrunent, the external Table may yield a little without breaking: By yielding it compr-eflrs the Air in the bony Cells of the 'Diploe; and the internal Table giving no Palfage to the Air, it will break. Thus that Counterblow happens, about which moft Surgeons are now agreed, aud which I hall further prove by the following Inflance. Mr. Mery dreffcd a Wound upon the middle Part of the left Parietal, which at firfi did not fecm to penetrate as far as the Bone, The Patient had an Hemorrhage 38 A 7reatfe of the morrhage thtrd the No'fe: His Eyes appeared, as it were, bruifcd, and very much inflamed: he was aCf fccd with a great Fever attended with convulfive Mo, tions. All thofe Symptoms raited a Sufpicion that there was a Fra&ure in the Skull, and confcquently an Efufion upon the Brain. Mr. Mery having made a crucial Incifion, fomrd that the Pericranium was not adherent to the Skull. The latter was fine, of a lively red, without any Fraaure; and becaufe the fame Symptoms continued fill, notwithftanding Phlebotomy, Mr. Mery faid, that fince the 'Pericranium was not adherent to the Skull, fuch a thing could not happen but by the Violence of the Blow, which not being able to break the firft Table of the Bone, had without doubt broke the fecond; and therefore he applied the Trepan, though there appeared no Fradtre. As foon as the Piece of Bone was taken off, he faw the fecond Table fplit, according to the whole Diameter of the Piece, and confequently the Crack reached farther ftill. He took off a great deal ot Blood diffufcd upon the dura Mater, which was almoft gangrened; and with the Help of Brandy, and the Care of that great Surgeon, the Patient was perfetly cured. Secondly, it is ftill more eafy to anfwer the fecond Ob}ction than the firft i and I can affirm, that there is hardly any young Man, but who has experienced it. I have tried a thoufand timts to break Boards or Pieces of Wood, holding them in my Hand, and firiking them againft fomething hard and they broke a thoufand times in a different Part from that which was ftruck. Nay, I happen'd fometimes to be in Church-yards, with a Defign to feparate fome Bones of the Head, which I wanted. To that End I took a Femur, with which I ftruck a whole Skull; and I obferved, Operatioms of S Rt I G R Y. 369 obferved fometimes that I made a FraCure in a Bone, three or four Inches under the Part which I ftruck. A Syftem is true, when it is grounded upon Experimcnts; and if all thofe who contrive new Syfitems every Day, would build them upon Experiments, we fhould not fee fo many Difputes in Phyfick and Surgery. It may therefore be faid that the Counter-blow happens becaufe the Part of a Bone which is itruck, confifts of bony Lamina fo well united, that they refilt all together, and do not break; but the Violence of the Blow reaching the whole Bone, there happens to be a Part, wherein there fame Lamine, though the fame in Number, are lcfs united and firm, and confequently all of them do not equally refitf the Force of the PBlow, and therefore yield and break. W H E N I was at my Father's, a Man, about a League from Vitre, bLci g firuck with a Cudgel upon the upper Part of the left Parietal, fell down upon the oppofite Side; The Surgeon of the Place dreffed him, and found a Wound in the upper Part of the Parietal, which did not penetrate to the Bone. Within a few Days, the Patient died, and was buried; but fome time after, the Lord of the Mannor ordered a firict Enquiry to be made into the Matter, according to the Cuflom of that Country. The King's Surgeons were fint for; andmy Father being one of them, I attended him. The Corpfe was dug out of the Grave. I opened it; and the Surgeon who had dreffed the Man, fheved me the Wound, in which I perceived no Fraciure by the Probe. I took off all the Teguments of the Skull, and viewed the Wound, where I only perceived a fmall black Spot; but in the lower Part of the fim; Parietal there were two Cracks, which met together B b at 30o A4 reage of the at their Ends, and formed a kihd of V. I fiawved tile Skull in its Circumference, according to Cuflom, and we perceived that the Cracks went through both Tables; but we were very much furprifed, when we flaw in that Part where the Wound was, and where there was a black Spot, the internal Table very muchl fralurcd. I obfcrved no Fracture on the right Side upon which the.Patient fell. MR. 'Ptit, who has proved publickly, that all Counter-blows are poilible in fome Skulls, gives us an Account of a Fat in his Pradice, not unlike that, which I have juft now mentioned. And if thc Reacdcrs, who are prepotfeffed in Favour of the Moderns, require further Proofs; Mr. Lapeyronle has not long finc (hewed the Skull of a Man, who died of a Defluxion in his Brcaft, and who being fallcn long before upon- the Middle of the Parictal, had a Wound without any Fra6ure in that Part of the B)one: But all the Signs of an Effuiion mloved that Surgeon to make Inquiries, which proved very advantageous to the Patient. He made an Incifion from the lower Part of the Wound as far as the Temporal; and perceiving a Split in. this laft Eone, he carried thle Inciion as far as the Ospetrofmii. Laifiy, four Operations of the Trepan, which he applied upon the Temporal, 'and all along the Split, cured the Patient. THE Moderns convinced of the Counter-blow by Mattcrs of Fact, have accounted for it conformably to their Hypothefis. They fay that a Man being fallen, and having fratured Part of his Skull, lofes his Senfes immediately; and that when he comes to himfclf again, lihe is fill fo flunned, that he is very likely to get two or three more Falls, and confiquently as many new Fratures. I don't Operat;ons of S t R G F. R Y. 371 I don't deny but fuch a thing may happen but I can affirm that moft of thofe I have feen trepanned (and thofe are in great Number, fince my Father trepanned feven in one Year, who all of them recovered) did not ftir from the Place where they fell as I was affured by thofe who faw their Fall$ or the Blow with which they were firuck. From whence it may be concluded that the Fa& objected by the Moderns, which I don't take to be impoffible, does not confute thofe I have juft nowv mentioned. THIRDLY, to anfwer the third Obje&iodn of the Moderns, I grant the Interpofition to be found between two Bones may break the Violence of a Blow, and prevent its reaching the contiguous Bonec Hence it is that learned Anatomifts difplay fine Mechanifms in Ofteology, to fhew how wife Nature ha~ been careful to fecure the humane Body from the Fractures, to which it would frequently have been expofcd. However, it ought not to be affirmed that this mechanical Difpofition is the fame in all Men; for the Sutures may wholly difappear, and make but one Bone of two; and then the Frature I fpeak of, will be poflible, as I fliall fhew by the following Obfcrtions, M R. Arnaud was fent for to a Man of Note, who fell backwards in his Chamber, and dircaly upon the Occipital. The Man loft his Senfes immediately, and voided fome Blood through the Ears., The Phyftcian and Surgeon of the Patient were fent for. The Surgeon finding that the Paticnt had fallen upon the Occipital, had a Mind to make an Incifion in that Part; but the Phyfician perceiving a fmall Tumor above the left Ear, faid it was mor~ e proper to open upon the Tumor, which was done: Sb ad 37L A eadtife of the and they found- a Separation of the temporal Suture, and a Slit in the Temporal it felf. BEFORE they proceeded further, Mr. Arnaud was font for, Who knowing the Patient had been found lying upon the Occipital, and that the Blood equally came out of both Ears, faid that a Ea&t of the fame Nature, which he had lately feen, made him conjedure the fane Complications would appear on the right Side: Which proved true; for they found in it tome Erafitres not unlike thofe of the left Side. Thofe Accidents happened for no other Reafon but becaufe the Occipital being very hard and thick, refited the Violence of the Blood; and the temporal Sutures being almoft wholly foldered, were bruifed, and the temporal Bone fplit. I have feen a Boy about-twelve Years old, who fcll from the Top of a Tree upon the upper Part of one of the Parietals. Thofe who faw him fall, affirmed that lie had not flirred from the Place; and lie loft his Senfes: Nay, fome Blood came out of the Earpn the Side of the Fall. My Father found no Fradure in the Wound, which was inconfiderable. But there was a large Tumor behind the Ear, on which an Incifion was made; and the Temporal happened to be fo much fradured, that it was necetlary to take off a great Part of the crotaphite Mufcle, in order to find out the Illnefs. The Trepan proved very fuccefsful and the Patient was well cured, abating a finall Deformity. For the Surgeon being obliged to take off Part of the crotaphite Mufcle, to fee where the Mifchief lay; in the very Place where its Fibers met, the lower Jaw continued to be a little on one Side, becaufe the Mufcle of the oppofite Side drew more firongly than that which had been weakened. Let us proceed to the fourth Objetion. - FOURTHLY, Op6e/atOnis of SUR R, GRY.e 3 -FoURTHLY, It is impofible for all the Suturcs of the Skull to be wholly obliterated, and for the Bones to be foldered toaether, as is uiital in old Meln, and I have feen it upon the Skulls of many dead Iodics, which I opened in the Prefence of credible Perfons, and upon which there was not any Sign of a Suture. It were in vain, in this Cafe, for the Moderns to mention the Conjunfions of the Bones as apt to break the Violnce of a Blow, and prevent its rac.hing the Part oppofite to the Bone ftruck. Therefore, in Skulls of fich a Strudure the Counter-blow mayvhappen, as it will appear by the followingInflances. Mr. 'Dionis fays in his Operations, that a Groom belonging to the Dukedee Chevreufe, going to water his Horfes, fell upon a Pavement: He loft his Senfes, and was carried home. That Surgeon found a Wound upon the Coronal, which he dilated; and having oblfrved a Fradure in it, he trepanned the Patient. That Operation did not recover his Scnfis; but three Days after, a Tumor appearing upon the Occipital,. Mr. 'Dionis trepanned him again. A great deal of Blood came out through the two Openings; and as it came out, the Patient recovered his Senfes, and was cured. THE fame Author gives us an Account of a Girl, of nine Years of Age, who was looking upon Pcopie playing at Nine-pins: The Bowl being thrown into the Air fell upon her Head. At firfi, he obferved two large Contufions upon the Parictals: He 0 -pened the largeft, and finding the Bone fratured, lihe trepanned it. Two Days after, the other Contufion not diminifhing, he was obliged to open it, and to trepan, becaufe he found a Frature in it. The Patient came to herfelf by Degrees, the Accidents difappeared, and fhe was cured. Bb 3 PER 374 A Treattfe of the PERHAPS thofe who read every Day thefe two Obfervations in that Author, will fay, as to the Groom, that he fell upon one of the Bones of his Head, and that rifing up he fell again upon the oppolite Side. In anfwer to the fecond Obfervation, they will fay that the Bowl fell- upon one of the Sides of the Head, and threw down the Girl upon the other Side; fo that one of the Fradures was made by the Bowl, and the other by the Fall. I anfwer that thofe Objeions are only grounded upon Surmifes, and mere Conjedures; and if things had happened in that Manner, the Author would have faid fo, and not given over the Opinion of the Moderns, to follow that of the Antients, as he himfelf owns. THE third Kind of FraCture, known by the Name of Contufion, is a Deprcflion in the Bone, made by a bruiting Infirument, that can break and bruifc the Eqnes of the Skull. ACCORDING to this Definition, there are two Sorts of Contufions of Bones; one, wherein the Continuity of the Bone is not deftroyed, as it happens to Children, whofe Skulls not having acquired their natural Solidity, yield in the fame Man, incr as a Pewter-pot. That FraCture is called a Depreflion in the Bone. THOUGH I have fecn a great many People trepanined, yet I never faw that Fra&ure but in Books, and never heard any able Surgeon fay that he had feen it. IHowever, I don't mean it is impoflible: The Softnefs of the Skull of Children may confirm it: But it may be faid that the Skull of a Child is not folid enough to bear any Operation, fuch as rhe Application of the Tirefond and therefore I advife the Surgeons not to attempt it without a very great Neceflity. ' ' ' *1 *' ' IN Operations of S u R G E R Y. 375 I N the fecond Sort of Contufion, or Depreiflon, the Continuity of the Bone is deflroycd, and there are feveral Sorts of it. FirJf, if the Bone is bruifed in fuch a Manner that there are many Splinters, and confcquently many Slits cutting one another at different Angles: This Mr. Arnaud calls a great Contufion. Secondly, The external Table may be bruifed and depreffed together with the internal: The latter will fly and fplinter, as one may fee in a Ball that goes through a Board: The Hole through which the Ball went in, is very even; but that Part of it where the Ball comes out, flies, and appears very uneven. In this Sort of Erafture, the Points pierce the dura Mater. Thirdll, There are great Depreffions, wherein a Splinter of a Bone lies partly under the found Bone: This Mr. Petit calls u Fra&ure with Splinters acrofs. Fourthly, There are Frafures, wherein Part of the 'Bone finks as it breaks: This is one Kind of Fracture, which is called a Depreflion. HAVING dcferibed the Fratures of the Skull, I fhall fay fomething of a Difeafe, which happens in the Brain by a Blow, a Fall, d&c. without any Fracture in the Skull, I meat the Commotion of the irain. MR. Petit fays, it happens feveral ways; for Infiance, if any one takes a Man by the Hair, and Thakes his Head to and fro, his Brain will be fo much agitated, that he will have a Commotion. IT may alfo be occafioned by foft Bodies, which not being able to frdAure the Skull, communicate their whole Motion to the Brain. This happens, for Inftance, when a Bottle of Hay, or fuch like Bodies fall upon the Head. Bb 4 THb 376 A 7~eatife of the TH E Commotion is frequently occafloned by a Fail, efpecially upon flat and even Bodies, which having no Unequalitics, can make no Fraaures; and then the Skull not being able to allay the Violence of the Blow, it muft needs be communicated to the Brain; from whence follows the Commotion. LASTLY, Mr. Petit fays, it frequently happens by a Fall uponr other Parts befidces the Head, as when a Man falls from a very high Place upright upon his Fet: By fuch a Fall the Brain is very much )fhaken; which occafions a Commotion. Some have died of this Sort of Commotion; and the Surgeons have fiound an Abfccfs in their Brain. THE diagnoftick Signs of a Fradure are all equivocal, and may appear in other Difeafes. For infiance, a Piece of Linncn put between the Teeth of a Patient, to fee whcther he can hold it, is no Proof of a Fradure; for that Sign would at moft difcover the Fratures, that are under the crotaphite Mufcle, and not thofe that affed the other Bones. Befides, the Difficulty of holding a Piece of Linnen might as well appear in the Contufions or Inflammations of the Crotaphite. T H AT fame Cloth, which fome Praditioners put between the Teeth of the Patient, and then pluck off with all their Might, that the Patient, feeling a Pain in that Part, wherein they fufped a Fradure, may lay his Hands upon it, and they may by that Means know where the Fradure lies, (in fuch Blows where there is neither Wound, nor Contufion, or a vcry fmall one) I fay, fuch a Sign is 1fill very equivocal, fince it may happen in a Contufion of the Frontals and Occipitals alone, and in the Contufion and Inflammation of the RPeriofleum. Nay, I.are affirm that Sign is often fallacious, and that a Patient may feel a con Operaiuns of S u P G E R Y. 377 a confiderable Pain in the upper Part of the Parietal; for inftance, in confcquence of a Contufion and Inflammation in the Aponeurofjs of the Frontals and Occipitals, and in the Teriojeum; I fay, the Paticnt will put his Hand there, as being a painful Part, when the Effufion and Frature are in the lower Part of that fame Bone, as I have already faid. THE Bleeding of the Nofc is not a more certain Sign than the former; it may be occafioned without a Blow, or by a Blow. In the firft Cafe, it is ufual in thofe Difeafes, that proceed from Repletion, and then it happens three feveral Ways.. Becaufe the Air, which continually paffes through the Nofe, thickens it. z. Becaufe its Blood-Veffcels are very thin. 3. Becaufe they lie upon a Membrane, which is itfelf ftretched upon Bones - and by the fame Reafon one may account for the Hemorrhages that happen after a Blow. THE Echymoffs and Blackncfs appearing about the Eyes, and as fome fay, the Blood that comes out of them fomctimes, as well as out of the Ears, I fay, thofe Accidents cannot be a true Sign of a Frature: becaufe they may happen in all the Obflrudions of the Brain by the Communication of the Veins of the Canthi, and the ~Preparate, with the Sinus of the Os frontis, &c. So that according to that particular Struature, as often as there is an Obftrucion inwardly, it will be communicated to the 0utfide, or from lthe Outfide to the Infide. As for Vomiting, we know that the Funaions are impeded by a mere Wound of the Pericranium. Therefore, Vomiting is not a certain Sign of a Fracture. THERE is nop need of alledging many Reafons to fhcw that a Fever is not an undeniable Proof of a Fradure 3 A Treatife of the rFrauirc, flnce it happens moft times upon the leafi Inflammation, whatever Part it be in. SIN CE Matters of Fa& confirm Reafonings, I Tlall infert here a Hiftory, which will give no fmall.Weight to what I have juft now advanced. A Child having got by a Fall a fmall Contufion in the Fore-part of the Head, was affeaed with fome of the Signs above-mention'd. His Surgeon blooded him four or five times, and perceiving that the Accidents continued fiill, notwithftanding thofe Evacuations, he propofed the Trepan. Whereupon Mr. Petit was fent for, who having examined the Child, told the Surgeon, That all thofe Signs might proceed from another Caufe than a Fradure; etpcci-.ally at a time when the Small-Pox prevailed, and confecquently that the Trepan might be put off. He got the Child blooded twice more, and the SmallPox appeared: The Accidents vanifhed, and the Child was cured of all his Difeafes without being trepanned, which perhaps would have proved fatal to him. THE Touch and the Sight are the moft certain Signs of a Fra&ure: all the others are mere Conjeaures, and may be found in a great many other Difeafcs. However, when they happen immediately after a Blow, and the following Circumftances are added to tlhm, an univocal Confcqucnce may be drawn from many equivocal Signs. WHEN tlhercfore a wounded Perfon has many of thofe Signs, which I have mention'd; three Circumftanccs ought to be minded. i. The Inftrument, with which the Patient was fLruck, its Figure, Matter, Lightnefs, or Hcavincfs. 2. The Perion who gave the Blow, to know with what Degree of 'Force he Yave it. 3. The Situation more or lefs Operations of SUR G ER Y. 379 lefs advantageous, which the Enemy had over the wounded Perfon. A probable Conjefure may be drawn from thofe different Circumftances. THE Signs, that difcover a Crack or Slit in the Skull without a Wound, are a hard Pulfe, a fmall flat Tumor upon the Blow, a kind of Flufuation, and Hardnefs in the Circumference. But if there are many Slits cutting one another at different Angles, the Tumor will be more raifed, becaufe there is more Blood, but always with the fame Circumitances: I mean a hard Pulfe, a Flutuation in the Middle of the Tumor, and a Hardnefs in its Circumference. IF the Frafure is with Splinters acrofs, that is, if there are Splinters, the Tumor will be large and flat, becaufe the Blood is no longer fupported by the Bones; and the Surgeon will feel a Piece of a Bone, which yields to the Impreflion of the Finger, and has fome Elafticity. IN order to know by the Touch, the Cracks and Slits of the Skull, when there is a Wound, the Surgeon ought to have a right Notion of the Situation of the Sutures, for fear he fhould miftake them for Fraftures: and to that end, let him ufe a Probe, with a Button at the End of it. I F the Wound lies in the upper and almoft hinder Part of the Parietals near the Sutura Sagittalis, he muft remember there is a Hole in each Parietal, and fometimes there is but one in one fingle Bone for both. Blood-veffels pafs through thofe Holes, and go from the dura Mater to the Pericranium, and from the Pericranium to the dura Mater; and they are often found obliterated in adult Perfons. I fay, the Surgeon mufft remember not to miftake thofe Holes for a Fradure, leaft he fhould apply the Trepan to no purpofe i which would always be prejudicial to the Patient. THE1R 38 o 3A Treatre of ihe T'H'HERE is ground to believe that the internal Ta1 ble is fratured, when the external is broke; but if the Surgeon perceives nothing at all in the external Tablc, and all the Accidents continue, he may fupedt that the internal is fratr'ed, if he has before examnined the whole -Head, to fee whether he can find any Tumor, that difcovers a Fraiubrc in another Place. IF, a cutting Inftrument makes a perpendicular or oblique Incifion in the Skull, and that Incifion reaches farther than the Angles of the Wound of the Teguments, 'tis a certain Sign of a Frafture; and to be fure of it, the Surgeon muft fpeedily dilate the,Wound and he will fee a Fradure in one, or both Angles of the Incifion of the Skull. But if after the Dilatation of the Wound, he only perceives upon the Skull the Mark of the cutting Inftrument, and if there are fome Accidents, which inclofe an Effifion, the Surgeon may be Lure that there is a Fradure in the internal Table of the Bone. WHEN a Ball makes a Wound in the Teguments, which penetrates to the Bone, it may be faid that in fuch a Cafe there is generally a Fradure in the internal Table, on in the 'Diploe and if fuch a Wound is never fo little attended with fonie of the cquivocal Signs above defcribed, the Patient ought to be trepanned without any Hefitation. IF after a great Fall, or a violent Blow, there is a Wound or a Contufion, attended with a FraCture, the Surgeon may be fure that the Violence of the Blow or Fall was loft in the Fradure. But if there is no Mark in the Bone, he ought to believe that the Difcafe lies elfewhere, as I have fhewed by the Poffibility of C0unter-blows. In fuch a Cafe, the Surgeon muft not only -examine the Parts lying near the Wound, Operath s of S UR GER Y. 3 Wound, but alfo, as Mr. Arnaud advifes, the belt Precaution, in doubtful Cafes, is to fhave the whole Head, in order to know what Condition it is in; and if a painful Tumor appears any where, it ought to be opened. THE Signs of an Effufion are a confiderableRednefs of the Eyes and Face, with a Drowfinefs; and thofe Accidents appear at the very fame time that the Effufion happens. On the contrary, when they appear only afterwards, there is ground to believe they are a Sign of a Frature in the 'Pericranium: which is further known by a great Oedema of the whole Head, excepting the Ears, as I have faid, and by the Pain of the wounded Part. The Surgeon is flill more certain that the Pcricranitm only is affeted, when all the Accidents are over, after he has made an Opening. THE Prognoflick of Fraurtcs is, that the moft dan gerous are thofe, that are not known; and according to this Do6trine, Contufions, capillary Slits, the Fractures of the internal Table only, and Commotions are very bad, and a Surgeon ought to be very wary in fuch Cafes. MR. Petit tells us, That a Soldier being fhot with a Gun in the lower Part of the Coronal, towards the great Corner of the Eye, had a Wound, which fnemed to be fimple. He was dreffed in the Hofpita!, and fometime after, the Patient being cured, refolv'd to go away, though the Major Surgeon advifed him to tfay longer. Hce was hardly come to the Gate of the Hofpital, when he was fcized with a Shivering, which forced him to come in again, and to go to Bed; and he died two Days after. His Body was opened: an Abfcefs appeared in the Srain; and the Ball that came in through the great Corner of the Eye, was found under 38.A Treatife of the under the Sella Turcica, and under the Holes of the Optick Nerves. I have feen a Girl of about eight or nine Years, who being at play, fell, and got a fmall Tumor in the Head. She was a little flunned for a while, and not long after fhe went again to her Play-fellows, her Parent not minding her Fall. A quarter of a Year after, fhe had a great Fever, a Rednefs in the Face, tfparkling Eyes, Convulftons, a 'Delirium, and a light Head. Laffly, notwithftanding the Care of an able Phyfician fhe died; and they found an Abfcefs in her Brain. I think there Obfervations, far from being a Digreflion from my Subje&t, undeniably fhew how carefully a Surgeon ought to mind thofe Wounds of the Head, the Importance of which is not eafily known: They will make him apprehenfive of fome concealed Mifchief, and even afford him, if he has.any Genius, curative Indications,' as far as they are poflible. IN general, when a Blow or Fall are violent, the Violence of either of them muff needs be loft in the Diforder of the Skull or Brain. This Truth may be proved by a plain Comparifon. If a Man holds a Board at one End with both Hands, and fitrikes violently the other End againft a hard Body, and it fplits, the Violence of the Blow being loft in the Slit of the Board, will do no harm to the Perfon, who holds it. But if the Board, by its Solidity or otherwife, refifts the Violence of the Blow, that Violence muff needs lofe itfelf fomewhere elfe than in the Board, and caufe a Commotion: This one may perceive by a Trembling and Numnefs in the Hands, and all along the Arms. THE Symptons, which happen immediately, are lefs dangerous than thofe, which happen afterwards, becaufc: Operai;ons of Su 1 GE R Y. 383 becaufe the former are a Sign of a fudde, Effufion, with which a Fra&ure is attended and if a Surgeon is fo lucky as to know that Effuion, he may hope for good Succefs: Whereas the latter difcover to us an Illnefs, without enabling us to find the Place where it lies; and fometimes they appear only to give us Notice of approaching Death. BESIDES thofe different prognoftick Signs of Fractures in general, and of Commotions, we have others, that concern the Bones particularly, and are more or lefs dangerous, according as the Bones are more or lefs fratured, and according to their Solidity. For Inflance, there is ground to believe that a Wound in the fore-part of the Head is fooner attended with a Fradure, than a Wound in the hinder-part, becaufe the Bones of the firft place arc thinner than the others, and confequently more apt to break. But it may be faid that the Fratures of the Occipital are more dangerous than thofe of the fore-part of the Head for feveral Reafons. i. Becaufe a greater Violence, and confec quently a greater Commotion, was requifite to break that Bone. 2. Becaufe it contains the Cerebellum and the Medulla oblongata, the Wounds whereof are mortal. 3. Becaufe it comprehends, in its middle Part, the lateral Sinus's of the dura Mater, the Opening of which would be no lefs dangerous. I fhall fhew by and by, that the Trepan cannot be applied upon the Sutures; from whence it follows that the Fratures in the Sutures are much more dangerous than thofe in the other Parts of the Skull. FRACTURES that are multiplied, and cut one another at different Angles, are commonly lefs dangerous, when the Pieces do not change their Place, and do not deftroy the Level of the Bone, than when they are depreflcd and jut out one upon another i becaufc 94 ýI.~TeA7eattfe of the caule in the atter, ntor only the Brain is vety much tompreffedi but alfo the dura Mater is pricked with the Points of the Bones: Which occaftons Inflamxflations, and frequently a Gangrene, not to mentionz, the Etfufion, which happens above and under that Membrane. VIOLENT Blows or Falls, which muft neceffarily caufe a Fraaure, are more dangerous upon the Temporals, at the top of the Head, and in the Fontaoella than any where clfe 5 becaufe the Bones being very thin in thofe Places, are broken by fuch Bodies as would only make a Wound upon the Tegaments of other Boscs. Befides, the Temporals are covered with Mufcles, and thofe Mufcles themfelves are covered with the 'Pericranium, and Apoaeurofis of the Frontals and Occipitals. That Struurt e makes them very tender, and is often the reafon why their Wounds are atterded with very fad Accidents, which fometimes deceive thole, who know not well the Difpofition and Mechanifim of thofe Parts. IF the Parietals are very thin in their fore and upper Parts, and confecquently apt to break by the leaft Violence, 'tis becaufe they do not offify in that Place till a long time after Birth. Kerkering fays flurther he found them feveral times membranous in adult Perfons. This Obfervation is of no fmall Impolrta'ice; for a Surgeon might be miflaken in the Wounds of the Head; and when he touches a Contufion or a mere Wound of that Part, and feels the Motion of the Brain, he might think the Skull is broke. But to avoid that Miftake, a Surgeon muff in fuch a Cafe ask the Patient and his Relations, whether it be a natural Thing, which they perceived before the Patient received the BloW, or got a Fall. Such a Caution ought to be ufced, Operations of S U.RG R Y. 3 8 ufed, for fear of making a bad- Prognoftick, which perhaps would move the Surgeon to perform an Operation more dangerous than the Illnefs it felf. THE Fraftures penetrating into the Sinus of the Eye-brows, are alfo dangerous, not only becaufe the Trepan cannot be applied upon them, butbecaufe the Cure is very difficult, by reafon of the ferous Humor, which runs continually, and may make them fiftulous. To make an end of the Prognofficks of the Fra &ures of the Skull, and Commotions of the Brains the Surgeon muff add to all I have faid, the equivocal Signs, that appear in them, fuch as Drowfinefss a Fever, the Blacknefs of the Eyes, d&c. the Age% Temper, and Strength of the Patient. He muft examin whether thofe Signs appeared with the Blow, or the Fall, or fome time after; and from all thofe Obfervations a right Prognoftick may be drawn, which will frequently prove ufeful to the Patient, and ad, vantageous to the Surgeon. CHAP. XL. Of the Operation of the Trepan, SINCE the Commotion is a Difeafe occafioned by a Blow, a Fall, or a Shaking, which diforders the Brain to fuch a degree, that it is attended with Symptoms not unlike thofe of the Fratures of the Skull, and of the Effufion upon the dura Mater $ and fince we don't know in what Part lies the Illnefs, which occafions the fad Symptoms and Abceffes attending that Difeafe, as 1 have proved by the foreC going 386 A Treatife of the going Obfervations; it follows that in fuch a Cafe Surgery is of no great ufe, and that a fpeedy and frequent Phlebotomy is the only Help it can afford. I faw a Man at the Hotel-dieu, who fell into a Quarry. All the Parts of his Head were examined, and noWound, nor even a Contufion could be found; but becaufe he loft his Senfes, it was plain the Brain had fuffered a violent Commotion. He was blooded feveral times in the Arms, and in the Feet, and jugular Veins, and then the Phyficians prefcribed the Emetick. ON the fourth or fifth Day, his great Drowftnefs turned into a ~Delirium, and fuch a Fury, that it was thought neceffary to tie his Arms and Legs at the four Corners of his Bed. Within a Fortnight he grew fo quiet and weak, that he could hardly ftand. At laft, he was cured with good Food given him to recover his Strength; and during his Sicknefs they gave him Broth with an open Spoon. A Surgeon, who defigns to perform the Operation of the Trepan prudently and cautioufly, muft have three effential Circumftances in view. The firft confifts in uncovering the Bone; the fecond in the Manner of piercing it and the third in taking off extraneous Bodies. AMONG the different Fra&ures above-mentionedi fome are attended with a Wound in the hairy Scalp, and others are without a Wound. To difcover a Frature of the Skull, attended with a Wound in the hairy Scalp, the Incifions that are made in it, ought to be fo direded as to pafs through the Angles of the Wound, if it be poflible, to avoid caufing a Deformity, and not to deftroy the Skin without neceffity........If Operations of S u R G FR.. 3 r IF the Frature of the Skull is not attended wi:th a Wound in the Teguments, but only with a Contuflion, the Incifion ought not to be made immediately. But the Surgeon muft handle with his Fingers the whole Contufion, that he may be fure of the Solidity, or Brittlenefs of the broken Bone; and if there is a great Rupture, and many Splintei's, as it werec floating, if I may ufe that Expreflion, (which may be known by applying the two Forefingers upon thd Wound, or Contufion, and prcfling alternately firft upon one Place, and then upon t'other) then the Surgeon may perceive that the Pieces yield, and have an Elafticity. In fuch a Cafe, it would be dangerous3 to drive the Infirument as far as the Bone, and to cut at once the Skin, the Mulcles, and the 'Pericraniurnm; for by conveying too haftily the Infirument upon the Pieces of Bones, that are not very folid, ond might be apt to deprefs them upon the dura Aiaters to prick that Membrane, and to occalfion great Difl orders. On the contrary, that Opening ought to be made in fuch a Cafe, by diffieaing, and that very gently. Nay, Mr. Arnaud fays, there is generally in fuch Cafes a Vacuity between the Pericraniumn and the Pieces of Bones; and when the Surgeon comes to it, he is to put his Finger iin, or a grooved Probe, and to make an end of the Incifion upon that Inflrument. ALL Authors defecribe exaaly, and, almoft with one accord, the different Figures of Inciftons. I never heard able Surgeons make thofe Diffcrences in their publick or private Leaures; and I have feen great Praditioners, who frequently performed that Operation, make generally the crucial Incifion, even upon the Sutures, and the crotaphite, e z M id 388 A 7Tredtife of bhe Mufcle, a ithout any Accidenf arifing from it. But becaufe the Fibers of the crotaphite, frontal, and occipital Mufcles ought to be ufid tenderly, as much as the Bigncfs of the Fradure allows of it, the Surgeon makes a longitudinal Incifion according to the Reditude of their Fibers; and that it may the better uncover the Bone in the fradured Part, he makes it longer; and if that Incifion is fufficient to apply the Trepan, the ýWound is fooner cured, and with lcfs Deformity. But if tlieFradure is fo confiderablc, that the longitudinal Incifion cannot uncover the Bone, it ought to be made crofs-wife. This Mr. Arnaud has pradiced with good Succefs upon the crotaphite Mufcle, whofe very Subitance he has cut away; without mentioning the Examples I have already alledged. THERE iS iflill another important Obfervation to be made with refped to the Incifions neceffary to difcover a Pradure. It confifts in cutting as much of the ~Pericraniumr as of the Skin, and even more, to avoid the drawing of the former, and the Bridelings it would form in the AngleCs of the WXound, which would quickly be attended with an Inflammation, and other fad Accidents. To make the Incifion well, I fulippofe a Contuflon upon the middle Part of the Parietal, attended with a Fradure, and confequently with an Effifflon upon the dura Matler, or the Brain, and the fratured Pieces to be firong enough to fiuflain the Impreffion of the cutting Infilumnent, without deprefing, or pricking the dura Mate,. The Incifion is m7ade in the following Manner. THE Surgeon takes a ftrait, or crooked Biflouri, upon the Back of which he Iclays the Fore-finger of his right Hand. He bears with the T humb of his left Hand Operatbois of SUR GER Y. 389 Hand upon that Part of the Skin where he defigns to begin the Incifion, and drives the Point of the Inftrumcnt, as it were under the Thumb, to the Bone, to cut more of the Pericranlium than of the Skin. Afterwards, he continues that firfF Incifton all along, without raifing the Infirument; and becaufe at laft the Skin is more cut than the Rericranium, efpecially if he has ufed a fitrai, Bilouri fomewhat inclined, he fhifts the Inftrument into the other Hand, and lays the Thumb of the right Hand upon the Extremity pf the Incilion, to make an end of cutting the 'Pen cranium in the fame manner as he began. IF that Incifion is fiufficient to difcover the Fracture, and to fix the Trepan, the Surgeon does not extend it farther, but when the Difeale is nmore confiderable, he makes a fecond Incifton, which cuts the firlt in the middle. He ufes the fame Caution in this fecond Incifion as in the firit, only with this Difference, that it ought to be interrupted, and made at two feveral Times Imean, that when the Point of the Infirument comes to the middle of the firft Incifion, the Surgeon mufft remove the Infirument into the other Hand, and apply the Thumb of his right Hand upon that Part of the Skin, which he defigns to cut, to make the fecond Arm of the Crofs, as I have already faid, and flop in the middle of the firfl Incifion. THE Defign of that fhifting of Hands is not to ihew the Surgeon is Ambidexter, but to cut the Tericranium parallel td.the Skin; for if the fecond Incifion was continued without any Interruption, as thq firit, the Skin being no longer flipported, by reafon of the firft a Divifion, would yield, and the Incifiork would not be regular. Cc 3 THE 390 ATreat;fe of the THE Surgeon, in the Operation of there Incifions, miuf cut the RPericranium as exa&ly as he can 5 and with his Thumbs or Fingers he is to loofen it from the Bones, together with the Angles of the Wound; which is eafy enough, when it is well cut. He muff alfo examine, without going farther, whether it makes no Bridelings, and he muft cut them; for they frequently occafion fome Accidents, which deceive the Surgeon. If fome Fibers of the Pericranium are fo adherent that they cannot be feparated with the Fingers, they muft be loofened with a Fleam. WHEN the Mufcles, that cover the Skull, are cut tranfverfly, or obliquely, with a Sabre, or any other cutting Infirument, the Skin fhrinks inwardly fo that it appears afterwards, that the Hair ofone of the Lips gets into the other; which occafions an Itching troublefome to the Patient, and the Scar is never well made: Nay, that Hair cannot be fhaved, becaufe it is'too deep, and frequently engaged in the oppofite Lip. To remove that fmall Accident, the Surgeon muft thruft the Bitlouri into the Middle of the Lip of the Wound, by which means there will be two Angles in it, which will unite, without folding thus upon one another. THE Surgeon having difcovered the Frature, with the help of thofe Incifions, and examined its Extent, muff fix upon the Time of the Operation. Authors put it off till the next Day after the Incifion, that is, four and twenty Hours after having difcover'd the Fradure. But that Time fhould not be to remote, fince the fooner that Operation is performed, the more fuccefsful it is; and if the Frature gives occafion to fufpe& that the dura Mater is pricked by the Points of the Bones, the Surgeon muft immediately perform the Qperation, and free the Membranes, as foon Operatons of SURGERY. 391 foon as poflible, from the Bodies that moleft it. By that means one may prevent fome Accidents, which frequently occafion the Death of the wounded Perfon. I believe, the Hemorrhage was the only Reafon that moved Surgeons to put off the Operation till the next Day; but if the Compreflion be ufed, three or four Hours are fufficient to flop the Hemorrhage; and if fome large Vefihels emit Blood, they muff be tied; and this laft Precaution ought to be ufed, when the Operation is performed immediately, and there is a conderable Lofs of Blood. IF the Operation be put off three or four Hours after having uncovered the Bone, and the Compreffion be ufed to flop the Hemorrhage, the Patient muff be dreffed: and becaufe the Surgeon defigns to flop the Blood, he muft fill the Wound well with large Tents, to ftop the fmall Veffels, and he muft raife the Dozels like a Pyramid, to keep the Angles of the Wound half reverfed; and at every Drefling he ought to deprefs them by degrees, to forward the Cure, and prevent Deformity. But if the Diforder of the fraaured Pieces is confiderable, and fome Pieces of Bones have a Motion, the Surgeons are to take care not to put any Dozels.upon thofe Pieces, and to contrive the Matter fo, that all the Lint may not exceed the Level of the Wound for to make a propping Point would deprefs the Piece. Ligatures would be of great ufe upon this Occafion, fince the Compreflion can hardly take place, and the Surgeon might lay, upon each Ligature, a fmall Comprefs, and the reft, as I fiall fay hereafter. WHEN it is thought proper to take off the Dreffing, in order to put in execution the fecond effential Circumftance for the Operation of the Trepan; care ought to be taken to remove the Comprefles and C c 4 ift 391 Treatintre qf the Plaifter, if they have been ufed, by the four Corners, in order to bring the Lips nearer to the Center of the Wound, and the middle Part of that Dreffing muft be taken off laft. The fame Obfervation ought to be made in relation to the Dozels, with which the Wound had been filled: thofe that have been laid upon the Arteries, or the fmall Compreffes, muff be taken off laft, without pulling them, for fear of opening the Veffel, and occafioning a new Hemorrhage. WHEN the Bone is wholly uncovered, when the Hemorrhage hinders the Surgeon no longer from feeing what Condition it is in, and he can examine the Nature and Place of the Frafure, he proceeds to the Operation of the Trepan. But before I defcribe the Method of performing that Operation, I think it will not be improper to take notice of thofe Parts, upon which that Infirument ought to be applied. IN general, the Surgeon is not to trepan the Sutures, becaufe he would tear the Strings of the dura Mater, which adhere very much to them. Befides, he might tear the Veffels, which pafs from that Membrane to the Pericranium, and from the Tericranium to that Membrane. The Surgeon muff not fix the Trepan upon the Middle of the Coronal, becaufe he would open the upper longitudinal Sinus of the dura Mater, which runs all along a Furrow formed in the internal Part of that Bone; and it would occafion an Hemorrhage, which could not be flopped without great Difficulty. This Precaution is chiefly ufed in the middle, and the lower Part of the Forehead, by reafon of the Spine of the Coronal, which adheres to the dura Mater; for the Trepan would tear that Membrane, and open fome Arteries on the Sides, while it faws that kind of Creft fo that the Operations of SURGERY. 393 the fame Caution ought to be ufed in thofe Parts as in the Sutures. HoWEVER, if there was a Fra&ure croffing the Middle of thofe Bones, or the Sutures, the Trepan fhould be fixed upon the Side of the Suture; and if the Accidents remained two Days after, the fame Operation fhould be performed on the other Side of the Suture and Fradure. THE Surgeon muft not trepan, without great neceffity, upon the Sinus of the Eye-brows, for he thinks he is upon the Brain, when he is only in the Sinus's, as we know by fome Inftances. The Operator may eafily undeceive himfelf by means of the Probe, and by dropping fome bitter and adoriferous Liquor into the Hole; for it is immediately fmelt in the Nofe. Befides, the Openings of thofe Sinus's remain generally fiftulous, and the Air comes through upon breathing fomewhat ftrongly, which is confirmed by an Obfervation of Mr. 'Duverney: That Surgeon fays, he faw a Man, who having been ftruck by a Splinter of his Gun upon one of the fuperciliar Sinus's, clapt his Hand upon his Plaifter every time he wiped his Nofte otherwife the Plaifter would have come off. THE Surgeon muff not trepan, neither upon the Middle of the Occipital, efpecially towards the lower Part of it, for the fame Reafons as he ought not to trepan upon the Coronal; nor upon the lateral Sinus's, which are commonly fituated under the tranfverfe Eminence of the lower and midlde Part of that Bone, becaufe he might open them, and Death would enfue. LASTLY, the Surgeon is not to trepan upon thofe Pieces of Bones, that have a Motion, and which appearing loofe, have not the Solidity which that Operation requires. IF 394 A Treatife of the IF there is any Piece of Bone in multiplied Fractures, that cut one another in their Angles, the Sur, geon muft endeavour to take it off; and when the Piece is removed, if the Opening be large enough to let out the diffufed Blood, and other Matters, there is no need of any other Trepan befides that which Chance has made. This I have feen in a Man, who being ftruck with a Laft by a Shoemaker, was carried to the Hotel-dieu, the 8th of Odober 1713. Mr. Mery found a finall Wound, in appearance, upon the middle Part of the right Parietal; but it appeared, by the Probe, that there was a confiderable Fradure. That Surgeon made a crucial Incifion, having laid bare all the wounded Part, he took off a Splinter, which was only the firft Table of the Bone. The next Day he took off two other Splinters and the dura Mater all black and gangrened came out with them. Mr. Mery put upon the Brain a Sindon dipt in warm Spirit of Wine, and over it fmall Dozels dipt in the fame Liquor, fome Plagets covered with a digeftive, &c. The Patient was dreffed much in the fame manner, all the Time of his Illnefs, and perfedly cured the 26th of 'December in the fame Year, contrary to Mr. Mery's ExpeCation. Bur when there is no Hold to take off the Splinters, or the natural Opening is not large enough to let out the extravafated Blood, the Surgeon is obliged to fix the Trepan upon a folid Part of the Bone, and as near the Fradure as he can, in order to take out the Pieces with the help of the Elevatory, as I fhall fay hereafter. THE fccond effential Circumftance of the Trepan, is, as I have already faid, the Manner of piercing the Bone; but becaufe that Operation lays open the Subftance of the Brain, expofes it to the Impreffion of the Operations of SURGERY. 395 the Air, and is attended with Difficulties, fome Precautions ought to be ufed to remove thofe Obitacles. FIRST, the Surgeon muft order the Patient to be fet in a Place, as free from Noifc and ill Smells as poffible. The Air is to be purified, by keeping the Doors and Windows fhut, and a good Fire in the Place, with a Chafing-difh upon the Patient's Bed, and fome Fire in it, during the Operation. Afterwards, the Patient muft be placed fo as the Surgeon and Servants, may ftand round him conveniently, his Head muft be kept fleady during the Operation; and in fuch a Situation that the Fracture may lie in the higheft Place, that the Trepan may fall perpendicularly upon the Part where it is. ALL this may be done, by removing the Bed from the Wall, that every Body may go round it, by putting a Pewter-difl under the Patient's Pillow, to keep him from finking and ftirring, and by getting fome Servants to hold his Head. CARE ought to be taken to put the Dreffing in a Dith laid upon a Table, till the Operation be over; and a Candle muff be lighted near that Difh, that one may quickly light again the WaxCandle, which gives Light to the Surgeon, if it fhould go out. The proper Inftruments muft be laid in order, upon another Difh or Baton, firft covered with a folded Napkin, and then- they fhall be put upon the Bed. WHICH being done, the Surgeon fhall take the Arbor of the Trepan, mounted with the Coronet that fhall beft fit it, with its Pyramid, and holding, with his right Hand, all thofe Inftruments joined together, by the Bafis of the Coronet, like a writing Pen, he fhall cotvey thcm fomenwhat inclined upon the 396 A Treat;fe of the the Part he has a mind to pierce - and raifing the Trepan gently, that it may fall perpendicularly upon the Part to be trepanned, he flall take care that the Teeth of the Trepan pafs a little over the Fracture, provided the Pieces be folid; and he fhall turn the Trepan two or three times, to make the Impreffion of the Pyramid upon the Skull. IF the Surgeon has a mind to ufe the Perforative Trepan, this is the time for removing the Coronet, and for fubftituting the other in the Mark engraved by the Pyramid upon the Skull, and by turning the Arbor of the Trepan from the Right to the Left, as I flall fay hereafter, the Surgeon makes room for the Pyramid,? Tat when he has a good Coronet, and a good Pyramid, he need not ufe the Perforative. The Pyramid muft be fteady in the Coronet, and not exceed it in Length above a Line, becaufe there would be fome Danger of piercing the dura Mater in a thin Skull. WHEN the Operator faws the Skull, he lays the Palm of his left Hand upon the Handle of the Tre, pan, refting it upon the Forehead, not fo much to bear upon the Arbor, as to make the Coronet fteady, and that his Sight may fall perpendicularly upon its Circumference. Afterwards, he claps his right Hand upon the fmall Ball, which is in the Middle of the Arbor, to turn it from the Right to his Left, in order to faw the Piece of Bone. Which happens two' feveral ways; for by prefling gently with the left Hand upon the upper Handle of the Arbor of the Trepan, the fmall Teeth of the Coronet cut the Bones perpendicularly; and by turning with his right Hand the Ball of the Middle of the Arbor, the Edges of the Teeth of the Coronet cut the Bone horizontally. THE Operations of S u RR. 397 THE Operator may go faft enough, when he bcgins to faw, becaufe there is nothing to fear; taking care however not to lean too hard with his left Hand upon the Arbor of the Trepan, left the fmall Teeth of the Coronet ihould fink into the Skull, which would hinder him from turning uniformly with his right Hand; and when he perceives that Inconveniency, he muft move his right Hand half way round from the Left to the Right, and then go on again gently. He muff alfo incline a little the Arbor of the Trepan on all Sides, to make more room for the Coronet, and more on one Side than on the other, when he perceives the Circumference of the Bone is not cut equally on all Sides. This he cafily knows, when there appears more Saw-duft on one Side than on the other; and the Infirument muft be inclined on that Side where there is leaft. WHEN the Coronet has fufficicntly cleared its way, the Operator removes the Trepan, turning the Coronet half way round from the Left to the Right, and then fets his right Hand upon the Bafis of the Coronet, and takes it off in that manner to remove the Pyramid, with the help of the Key. Afterwards he takes care to fweep away, with a inall Brufh, the Duff that lies upon the Skull, to remove that which is in the Mark of the Coronet with a fmall Toothpicker, and to clean the Coronet with the fame Eruth. He applies the Trepan again, holding it, as I have already faid, like a writing Pen, and inclined, that it may enter at once into the Opening, which he has begun to make in the Skull; and he raifcs it gently to refume its firft Situation, in order to go on with the Operation. But he muff rcmember that the Pyramid has been removed, and confequently that he muft turn more gently, for fear of going wrong way. As 398 A Treatfe of the As often as he perceives any Refiftance in the Co" ronet when he turns the Arbor of the Trepan, 'tis a Sign the fmall Teeth of the Coronet fink too deep. He muft then turn half way round from the Left to the Right and begin again, but a little more gently. IF the Operator has a mind to ufe the Tirefond in order to remove the Piece of Bone, I think it more proper to mark out the Circumference of it before he comes to the Diploe, becaufe by making a Screw in the Piece of Bone with that Inftrument, he gives a circular Turn, which would be ftrong enough to dia vide the firft Table from the fecond, if the 'Diploe was fawed; and though that Fault be not in the main prejudicial to the Patient, yet it makes the Ope& ration more difficult and longer. THE Operator applies the Coronet again, and continues to faw, till he comes to the 'Diploe. Surgeons skill'd in thofe Operations are foon fenfible of it, becaufe the Bone is not fo hard to cut, and they feel a fmall cracking Noife in that Hand, which holds the Trepan. Befides, the Duft gathering about the Coronet grows a little redder than that of the external Table of the Bone. WHEN the Operator is come to the Diploe, he muft go on more gently, raife the Trepan frequently, in the manner above-mention'd, fweep the Saw-duft which the Teeth of the Coronet feparate from the Bone, and put the fmall Tooth-picker into the Hole of the Coronet, not only to take out the Duff, but alfo to know the Depth of the Opening: and therefore that Tooth-picker ought not to be flarp-pointed, becaufe when the Operator comes near the dura Mater, the Skull not being equally thick every where, he might thruft it into thofe Parts that were firft fawed. IT will not be amifs to have two Coronets of the fame Operations of SU RG R Y. 399 fame fize, that if one fhould happen to fail, the Surgeon might make an end of the Operation with the other; and if thofe Coronets want a little Oil to make them cut better, he may put in fome to facilitate the Operation. THE Operator fhall frequently endeavour to fhake the Piece with a fmall filver or fteel Lever, one end of which muff be like a Chifel, very narrow, pretty thin, and fomewhat rounded; and the other crooked, for the Conveniency of many Operations. He is to continue to faw gently, taking care, as I have already faid, to incline the Coronet on that Side where the Bone does not appear to be cut equally: which commonly happens upon the Parietals, by reafon of the Convexity of thofe Bones. The Piece muff nor be fawed too much; for one might not only tear the dura Mater, but alfo open fome Arteries creeping upon that Membrane, and lodged in the Scilturcs engraved in the internal Part of the Bones of the Skull, as there are fome pretty deep in the Parietals, efpccially in their lower Parts: however, the Surgeon muff leave as few Inequalities as he can. HE endeavours again to fhake the Piece of Bone with the fmall Lever above dcfcribed, for which we are indebted to Mr. 'Petit; and if he perceives that it does not flick much, he pulls it off. Laftly, he examines that Piece, and if he perceives fome Inequalities in it, 'tis a Sign the Trepanning is rightly made4 THE third effcntial Circumflance confilts in removing extraneous Bodies: Thole that appear firft, are the Inequalities which the Coronet leaves in the Circumference of the Hole. Before the Surgeon takes them off, he muft prefs a little upon the dura Mater with the Meningophylax, to open a Way for thelnticuar Knife. Butt that Operation ought not to be petformed 4oo00 A Treatfe of the performed, before the Surgeon has heated the but2 toned End of that Infirument in the Palm of his Hand: The fame ought to be obferved with refpef to the lenticular Knife; for nothing cold muft be applied upon the dura Mater, or the Brain. To take off the Inequalities, which the Coronet has left in the Circumference of the Hole, the Surgeon ufes the lenticular Knife, with which he cuts, at feveral times, thofe fmall Points of Bones, that might prick the dura Mater. He holds that Inftrument faft with the four Fingers of his right Hand 1hut r and Mr. Arnaud fays, that if there is no Fracture, one may lean with the Thumb upon the Bone, to have more Strength. But if the Fradure reaches to the Circumference of the Opening of the Skull, Mr. Petit advifes us to ufe the Thumb of the left Hand, in order to raife the Thumb of the right Hand, and to ferve it inftead of a propping Point. WHEN the Inequalities, which the Coronet had left, are taken off, one muff let out the Blood diffufed upon the dura Mater. That Blood is frequently of two forts. The firft, which appears fometimes after the removal of the Piece of Bone, is of a fine lively Red, and fluid. There is ground to believe that fuch a good Blood is not that which occaflons the Accidents, and that it proceeds from the VDiploe, which has been cut. But when the Surgeon fees under the firft Effufion, a blackifh, thick, and clotred Blood, and a fmall Part of it adhering to the dura Mater, there is ground to think that this is the Blood that was diffufed by the Fradture, and that Trepanning muft needs be very beneficial. To let out that Blood, or the Pus, if there is any, the Patient muft fhut his Mouth, and make a ftrong Infpiration Opertions Of SUR GER Y. Rb Infpiration and immediately let fome Body qiifioe his Nofe, that he may make a great Expiration. The Surgeon will then fee the Hole of the Trcpan frill of Blood, which he muft fuck up with a finall Piece of fine Spunge, firft dipt in warm Wine,and vdell fq ueezed. Afterwards, let the Patient breath a little to repeat the fame thing-; and whilft he endeavours to make a great Expiration, the Surgeon fhall prefs a little the edura Mater with the Meningoplylax, w'hich heThall hold with one Hand, whilft he conveys with the othcr the Piece of Spunge, that it may be imbibed vith Blood. IF the Brain diftends itfelf, when the Patient makes a great Expiration, after the fhutting of his Mouth and the fqueezing of his Nofe, 'tis becaufe in that Affion the Diaphragm happens to be in fucli a violent Contraftion, that its two Tendons come very near one another, by which means the lower Aorta, which runs between themtn, iuffl needs be very much compreffed, and confequently Part of the Blood will not defcend to the lower Parts. That Blood will therefore run back, or force that which comies behind to get into the Arteries, that go to the Head from the Bending of the Aorta. Thus the Brain will be overflocked with Blood, and confequently dilated in that Expiration. THIS Argument is fupported by an obvious EfTed; for the Patient's Face grows extremely red at the Time of the forced Expiration, which cannot be explained brut by the Blood's running too plentifully into it. T'E 'EDiura Mater mutt lie open to the Air as little as poffible, becaufe the Impreflion of that fluid is very prejudicial, and brings upon it an Inflammiation attended with fad Accidents. THERE is a third fort of extraneous Bodies, thliat' Dd arc 4o0 A Treatife of the are to be removed, viz. the Splinters of Bones, which may fometimes prick the dura Mater, and the loofe Pieces occafioned by a great Frature, and by many Slits cutting one another at different Angles. If thofe Pieces of Bones lie feparate, they muft be taken off with Pincers that have Rings, becaufe the Surgeon has a better Hold with them. But he muft remove them gently, efpecially when there may be fuppofed to be Points engaged in the dura Mater; for if he fhould pull them hard, he might open a Sinus, which is a Mifchance he could not eafily remedy. In fuch a Cafe, he muft rather apply a fecond Coronet of the Trepan, always in a folid Part, to let out the cxtravafated Blood, and take off the Piece of Bone more eafily with the Elevatory. IT happens in fome Fradures, that a Splinter of lone gets in between the dura Mater and the Skull. The Surgeon then is obliged to apply two, three, or more Coronets, that he may be able to take off the Splinter, which compreffes the dura Mater; and he cuts by degrees with incifive Forceps the Angles too acute, that remain in the interval of the Coronets. THE Coronets are multiplied according to the Fractures. In thofe Slits that are long, the Operator applies two Coronets at the Ends, one on one Side, and th'other on th'other Side, taking care that they alwas pafs over the FraLture. In the Slits betwixt two Bones he applies one likewife to each Bone. Laftly, if he has a Mind to fcparare the Partition or Interval of the two Coronets, he faws the Piece of Bone on each Side as far as the DDiploe, or a little beyond it, with a fiall Saw, convex on one Side, and ftraight on the other: Afterwards he takes off the Piece with the Elevatory. If he fufpeas that the Partition Operations of S u G e a y. 403 Partition is not folid, he makes it faft with the ElevaL tory to Law it. WHEN the Vplo0e is vitiated, and there is a Coni tufion in it, the fame Accidents appear as in the Frature of the two Tables s and Trepanning is the only Remedy. But if nothing comes out through the Hole, when it is taken off, and the Accidents ceafe, 'tis plain the fDiploe was the only affeted Part. IF the Operator thinks it is abfolutely neceffary to apply the Coronet of a Trepan upon a Piece of Bone which does not appear very folid, he raifes it with an Elevatory, taking care not to ufe the oppofite Bone as a fixt Point, for if it was tender, it would be cruihed; and if it made no Refiftance it would fink upon the dura Mater. WHEN the Surgeon has fufficiently opened thd Part, with the help of the Coronets, if he thinks fit to raife fome Pieces that are funk, he ufes proper Elevatories; for there are feveral forts of them according to the differeat Fraaures. He holds that Lever with the right Hand, and paffes it under the Piece of Bone he has a mind to raife, taking care, as I have juti now faid, not to reft it upon the oppofite Bone; and during that time, he bears with the Thumb of his left Hand upon the Piece, which he raifes, to fupport it on all Sides. Now the Patient muff be dreffed. The firft Piece of the Drefling is the Sindon, which is a fmall Piecq of Linnen cut round, or fome Lint tied in the Middle with a Thread. But the former is preferable, becaufe theThreads of Lint are apt to fcatter. That Sindon mufft exceed the Circumference of the Hole, at leaft by one Line, not onlr that it may better flick where Ddait 40 4 A Treatife of the it fhould, but alfo becaufe being engaged under the Circumference of the Hole of the Trepan, it blunts the Edges of it, which might prick the dura ft-er in the Motions of the Brain. MR. Arnaud lays, 'tis better to apply a dry Sindon than dipt in any Medicament, becaule it can more cafily -be adapted upon the dura Mater than when it is wet. The Meningophylax or lenticular Button ought not to be ufed, (as is generally pra&iced) to apply the Sindon, and pafs its Circumference between the Skull and the dura Mater, becaufe one cannot fee whether the Thread that tics it be in the Middle: It is better to ufe the crooked End of Mr. 'Petit's fmall Lever. Afterwards the Surgeon pours fome Drops of a proper Medicament upon the Sindon; and the beft that can be applied upon the dura Mater, is the white Balfatm of Fioraventi a little warm. In the next place the Surgeon fhall lay upon that Sindon fmall round Plagets of the Bignefs of the Hole, and dipt in the fame Balfam: He muff lay two or three, according to their Thicknefs; for the Iole of the Trepan ought to be filled with them, to 'comprefs the durd Mater gently, in order to keep. it from moving out of its Sphere, and to prevent by that means the Hernias of that Membrane and of the Brain, which arie geverally mortal: Wherefore the Surgeon muft always keep his Finger upon that Part, wheii he dretiTs thofe forts of Wounds, and remove it only to put in new Pieces of the Dreffing. Above thdfe- fhmall Plagets he lays.two other larger, and dipt in the fame Medicament. Laffly, the remaining Part of the Wouaid muff be drefled, I mean, with 'Plagets covered with a digeffive Ointment, for there is no need of filling up the Wound but when the Operator has rmade the nccffary Incifions to difcover Operations of S UR GER Y. 405 cover the Fra&ure; and in the next D'reffings, the Dozels muff be laid afide, and care ought to be taken to bring the Lips of the Wound as near together as poflible. That whole Drefling is covered with Comprcflcs dipt in warm Spirit of Wine and Oil of Roles, without ufing any Plaifters, which flop the Pores of the Skin, and retain the Suppuration within the Wound. The Whole is fupported by a Comvrechef. Of the great Couvrechef, or the fquare Couvrechef. To make this Bandage, the Surgeon takes a Napkin longer than it is broad: he folds it tranfverfly in fuch a manner that one of the Ends comles over theother about two or three Fingers Breadth. ThAe he folds it double again, taking care that the longer End be inwards, and the other outwards. This laft Fold being only to mark the middle of the Napkin, it muft be made more vifible, by prefirnig it a little with the fore-Finger and Thumb of the left Hand. Afterwards it is ulual to put the Fingers of each Hand within the Napkin, ori both Sides of the Fold, and to clap the Thumbs upon the Out-fide, in order to convey the Napkin thus, with both Hands, upon the Patient's Head. But that Method is not elegant, and may fometimes be prejudicial; for the" Surgeon being obliged to make half a Turn, in order to lay the fhretched Napkin upon the Patient's Head, his Sleeves-may hurt him. The Surgeon muff therefore make that Bandage more elegantly, and avoid that Fault, by holding the Napkin only with ohe Hand, (the Fingers within, and the Thurmb without, as I have juft now faid) conveying it upon the Patient's Head behind his Back, and raifing it there widn both Hands, for fear of dilbrdering the Drefing. D d 3 Afterwards, 4o6 A Treattfe of the Afterwards, he muft let the Napkin fall gently upon the Dreffing, taking care that the Fold be at the Root of the Nofe, or fomewhat lower. The four Angles of the Napkin, according to that Situation, hang down upon the Clavicula, Then the Surgeon bids a Servant, or the Patient, hold the two external Angles under the Chin, whilft he takes the internal Angle of each Side over-againft the Chin, taking care that the four Fingers be outwards, and the Thumb inwards. He removes thofe Heads on both Sides of the Chin, and then raifing his Hands a little, he turns back by that Motion the Fold of the Napkin, which comes as far as the Nofe i and conveying the Heads towards the Nape, he forms feveral Folds neat the fmall Angle of the Eyes. When the Heads are at the Nape, the Surgeon unpleats the Napkin with his Fingers, that the Bandage may be neater, and the Patient not troubled with a Heap of Linnen. Afterwards, the Surgeon croffes the Heads upon one another, and ties them with a Pin as low as he can. AFTERWARDS the Surgeon muff come before the Patient, and take, with one of his Hands, the external Heads, held by a Servant or the Patient: and then he maft convey the four Fingers between the Cheek and the internal Head, and the Thumb into the Doubling of that fame Head, where there is a a great Cavity called Sinus by the Antients. There the Surgeon muft dr4w the Head dire&ly downwards, to level many Pleats, and make the Bandage more even, and then he muff draw the Head backwards to difincumber the Cheek. The Surgeon does the fame on the other Side, taking care to hold with the other Hand the Heads that are under the Chin. Now thefe iHads muft be made faft, and if they are fhort, they muit Operations of S R G ER Y. 407 muft be pinned under the Chin; but if long, they muff be tied. That Knot is little regarded; and yet when made very neatly, it is eafy to the Patient, and very much fcts off the Bandage. To have it according to my Fancy, it fhould be double; but whilft it is yet fingle, the Surgeon is to draw the upper Head under the middle of the Chin, and fet it a little on one Side. Afterwards, that Head is twifted round the lower one, to make the fecond Knot; and thus one may have a Knot neatly made. THE two Sides of the middle of the Napkin remain ftill, and hang down upon the Back and Shoulders, like a kind ofBifhop's Camail. If they are fhort fome Surgeons fold them double, and put them round the Neck to tie under the Chin. If they are long, thofe Surgeons are for lifting them up but to do it neatly, the Surgeon mult fiand by the Patient's Side, and remove all the Folds that are in that Side of the Napkin, which hangs down upon the Shoulder, and then fold that fame Side in its Forepart according to its whole Length, and about three or four Inches in Diameter, to convey it towards the middle and upper Part of the Coronal, where he ties it with a Pin. The Surgeon does the fame thing on the other Side of the Patient; which produces behind the Head a long Point like the Hood of fome Monks: it muff be pulled fideways to pin it in both Sides. THE Camail being thus railed and fitted, forms a kind of Cap over the Couvrechef, which keeps the Head warm and that whole Bandage is very neat, and fupports the Dreffing yery well. WHEN two or three Coronets have been applied pear one another, the Surgeon muft lay a Sindon, D d 4 a+cor.ing S4 0 8 A Treat fe of the according to the Hole, in the Skull, and over that Sindon imall Compreffes one upon another, to refit the Motion of the Brain. WhiCh is the Reafon why Mr.Belojie has contrived a leaden Plate with two Handles, that are laid upon the external Part of the Skull, as one may fee in his Book. But it is of no great Ufe, fince it is only fupported by the Dreffing which is above it, and the Iumpulflion of the Brain may remove it from its Place. And therefore Mr. Petit has invented one of a quite different Stru&ure. To fit it to the Bignefs of the Hole he lays, in dreffing the Wound, a Paper upon the Bone, which adapts itfelf exadly to the Figure of the Hole. Afterwards he cuts the Paper, which ferves as a Model to cut the leaden Plate. He ties it in the Middle with a Thread, and lays it upon the Sindon. He faftens that Plate with a fmall tranfverfe leaden Lamina, a little longer than the Plate, which refts under the Bone. The leaden Plate muft alfo be tied with a Thread. Afterwards the Surgeon dreffcs the Wound, in the manner I have faid. THE Trepan muff be dreffed twice a Day, if the Suppuration be copious, efpecially when there is a confiderable Effufion. Care ought to be taken to make the Patient infpire and expire fo as to let out the ~Pus. The Chamber muft be kept fhut and warm, efpecially in cold Weather. Whenever the Wound is to be dreffed, there ought to be a Chafing-difl hard by, and the Bed-curtains muff be drawn. THE Patient muft in general be kept to a very regular Courfe of Diet: he fhould be frequently blooded the firft Days, tho' flill in proportion to his Strength and the Violence of the Accidents. For if the dura Mater was inflamed, the Fever violent, &'c. Phlebotomy Mhould accordingly be more frequent. Clyfters Operationus of S u R G R Y. 4.09 ClyfRers are alfo of gre4 Ufe, and have a goo.d BEff e by relaxing the Bell(y CHA P.XL. Of the Aneurifim H AVING deferibed, as exaaly as Icould, the Opevations commonly pradiced in the three Cavitics of the Trunk, and their Circumference, the Order I have preferibed to myfelf, requires that I ihould now difcourfc of the Operations that are proper for the Extremities. I fhall begin by the Cure of the Aneurifm. W1E mean by that Word a Tumor, confifting of arterial Blood, occafioned by the Dilatation of fome Artery, or an Effufion of Part of the Blood contained in it, attended with a Pulfation more or lefs fenfible, according to its Extent or its Differences: And by reafon of that Diverfity, Authors have afign'd two forts of Aneuriftis. The firit, which they calltrue, is a Tumor made by the Dilatation of an Artery, and always attended with a Pulfation, which leffens, as the Tumor grows bigger. The fecond, called a fpuriozs Aneurifr, is a Tumor made by an Effifion of the arterial Blood, occafioned by the opening of an Artery, and which is not attended with an interrupted and diftint Pulfation, but with a kind of hollow Noife, or rather a Whizzing, which encreafes as the Tumor grows bigger, and more arterial Blood is diffufed into it. THOSE two forts of Aneur9fm proceed from internal and external Cafes. The true A 4ewrtfm is commonly 41o.A Treatife of the monly occaioned by great Agitations, and violent Mo" tions in thofe Parts where the Mufcles exert themfclves moft. It proceeds alfo from Compreflions, occafioned by bony or humoral Tumors, as is feen to happen in the intercoflal Arteries by the Exoflofes of the Ribs, in the Clavicula, the Humerus, the Elbow, and in the Artery, which pierces the Ligament betwixt the two Bones. The fame Aneurifm happens alfo in the axillary Artery near the Head of the Humerus; and upon that account the Surgeon is obliged to make the Amputation in the Articulation. THOSE bony or humoral Tumers, compreffing the Artery that lies neareft, or which paffes into their Body, as it may happen in the latter 'tis plain, the Blood will rather flop in that Place than in the remaining Part of the Du~t: And when this happens, the Serofity of that Blood flopped muft needs feparate from it, and pafs more eafily thro' the Pores of the Artery. The Membranes of the Artery, being imbibed with the Serofity, that feparates from the Blood, grow more pliant, loofer, and confequently more capable of yielding to the Motions of the Heart. Thus the Artery dilates, and makes a Bag, which becomes more or lefs confiderable, according to the Parts wherein it is formed. A Serofity proceeding from fome adjacent Parts, and diffufing it felf upon the Artery, may relax its Membranes, and for the fame Reafons occafion an aneurifmal Tumor. AN Abfcefs near an Artery may alfo be the Caufe of that Difeafe, not only becaufe it may relax that Veffel, but alfo becaufe the Pus corroding the external Membrane of the Artery, or the Capfula that contains it, it is no longer able to refift the Impulfe of Operations of S uR GR. V. 41t of the Heart, with the fame Force. Therefore at every ftroke of the Pifton, the internal Membrane of the Artery will be forced to yield a little, and at laft to make a Hernia of the Artery. Thus an Abfccfs may occafion an Aneurifm. LASTLY, Fratures may produce a true Aneurifinm, by Splinters or Points of Bones, which tearing the Capfula or external Membrane of the Artery, weaken it in that Part, and confequently render it lefs capable of refifting the repeated Impulfes of the Heart, &c. AMONG the external Caufcs of the true Aneurifnm, fome of them bruife the Membranes of the Artery fo much, that the Blood diffufes it felf into the Interftices of their Fibres, and relaxes them in fuch a manner, that they are forced to yield to the Blood, which is always propelled by the Heart; and from thence follows an Aneurifm. This happens by a Blow, a Fall, &c. upon thofc Parts. THE opening of the external Membrane of the Artery does alfo frequently occafion an Aneurifm, as appears by Blooding, when the Point of the Lancet has only touched the external Membrane. Mr. Arnaud does not deny the Faf; but he fiys, the Difeafe is rather a Confequence of the opening of the Capfula, or Sheath which contains all the Vefels, and that the Artery which beats ftill, meeting no longer with any Refiftance in that Place, the Artery pafiers into it by degrees, and Forms a Hernia: Which is the proper diftindive Sign of a true Aneurifin, and it may alfo be occafioned by any other cutting Infitrument. THE fpurious Aneurifim is produced, as I have already faid, by the opening of an Artery, and proceeds, as well as the true one, from internal-and external Caufes, THE 412 / Treatffe of the THE internal Caufes of the fpurious Aneurtifm ar much the fame as thofe of the true; for the Tumsor in this Aneurifm being very confiderable, and the Membranes of the Artery being very much dilated, lofe their claftick Virtue; fo that being no longer able to refift the Impulfe of the Blood, they are forced to yield, and break. The Blood comivng out thro' the Opening, diffufes it felf into the Interflice of the Mufcles round about the Artery, raifcs the Skin, if the Difcafe lies in th e cxtreme Parts, or is fupcrficial, and by that Means occafions the fpurious Aneur*n. Therefore the Ipurious Aneuriyfn may be fuperadded to the true. THE external Caufes of the fpurious Ancuri/ are alfo the fame as thofe of the true, viz. all the InfIruments, that can prick, cut, tear, e'c. fuch as Lancets, Swords, or hooked Naiis Only with this difference, that thofe Infiruments in this fort of Aneurifm open the Artery wholly, and give in an inflant a free Paffage to the Blood. Mr. Petit fays, there are two Sorts of fpurious Am'eurifi s. The one, when the Skin is opened together with the Artery This happens in Blooding, or in Wounds occafioned by other pointed and fharp Infiruments, which opening the Skin, open alfo the Artery. The fecond, when the Artery is opened without the Skin. This frequently happens in the Scrotum, as I faid, fpeaking of the Hydrocele, in the Tumors of the Bones, in the Broachocele,, in Wens, in incyfted Tumors, efpecially near the Knee. THE diagnoftick Signs of thofe two forts of Aeneurifzs are very different. The true Aneurifm appears like a fmall Tumor round and raifed, and attended with a fenfible Pulfation, and the Skin always preferves its Colour without any Alteration. If the Surgeon Operatfons of S U R G F R Y. 4T3 Surgeon touches the Tumor, he perceives there is in it a Liquor, which makes it foft and elaftick; and if he preffes it with his Finger, it withdraws from it. THE quite contrary happens in the fpuriouar Ane#-. rifm. The Tumor, far from being round and raifed. is flat, and very extcnfive: No regular Pulfation is felt in it, but a kind of Tremor: The Skin loEs its natural Colour, and becomes purple and black: If the Surgeon touches the Tumor, he perceives fome hard Bodies in it: Laftly, if it be pref'ed, it cannot yield and withdraw. I have faid that the true Aneurifth is nothing but the dilatation of the Artery; and therefore one may eafily conceive that the Blood filling u'pthe Bag equally, the Tumor muft be round, raifed and frnooth. *WHEN there is a fenfible Pulfation in the true Alneuryfm, it may be explained, vith all its Difflc rences, by the natural Mechanifni between the Heart and the Arteries. Every Body knows the -Heart is a hollow Mufcle, which forces the Blood into all the Arteries, as it were, with Strokes of a Pifton regularly given, and the Arteries are Tubes, which may be diflend-d by a Aierior Force, and have an Elaflicity to refiume afterwards their natural State. Wherefore as often, as the Heart drives the' Blood into the Arteries, they are forced to yield to its Violence, and to dilate; but as foon as the Heart ceafes to drive the Blood, the Arteries unbcnding themfelves, comprefs the Blood contained. in them, are Antagonifis, as it were, to the Heart, and are one of' the chief Caufes of thc Circula. dion. WVherefore a Pultation happens to be in the true A.,neurfin becautý the Blood, which makes the Tumor, is covered with the Membrancs-of the A rter, 414 A rreatife of the Artery, which by their Elafticity make a Reiftanct to the Heart. But becaufe, as the Tumor encreafes, thofe Membranes grow thinner, and their Fibres are lefs able to refift the Impulfe of the Heart, it follows that their Pulfation is not fo ftrong. Therei fore in the true Aneurifm, the Pulfation leffens, and the Tumor encrcafes. THE natural Colour of the Skin depending only upon the regular Circulation of the Juices, with which it is imbibed, and that are under it, it follows, that in the true Aneurim the Blood, which makes the Tumor, having a Communication with the Blood that runs in the Artery, muff preferve its Fluidity and Heat by the Concourfe and Mixture of the new Blood, the Motion whereof is continual, and confequcntly not being corrupt, and its Parts preferving their Regularity, the Skin that covers the Tumor, muft neceffarily preferve its natural Colour. THE Softnefs and Elafticity of the Tumor, when It is touched, and the withdrawing of the Blood, when it is preffed, may eafily be explained by what I have juft now faid. THE fpurious Aneurifm being a Tumor made by the Effufion of the Bldod, by reafon of the Opening of the Artery, and that Blood being no longer rcftrained within the Pipe that contained it, it muff needs diffufe itfelf on all Sides, and fo form a flat and extenfive Tumor. BUT the Blood coming out continually through the Opening of the Veffel, will quickly make a confiderable Tumor, or diffufe it felf through the whole Part and if it be in the Arm, it will rather afccnd towards the Shoulder than towards the Wrift, becaufc the Aponcurofes of the Extenfors of the Arms being ftrongly faften'd to the Articulation, the Blood afcends more Operations f S U R G R Y. 41 more eafily, and frequently diffufes it felf into the whole Side, which thereby fometimnes becomes exceflively fwelled and tumefied. THERE is no fenfible Pulfation in the fpurious Aneurifm, for two effential Reafons. Firft, becaufe the diffufed Blood, which chara&terizes the Difeafe, has no longer any Communication with the Blood of the Artery. Secondly, becaufe the Arteries in their Pulfations are (as I have already faid) Antagonifts to the Heart; and when the Fibres of all the Membranes of the Artery are disjoined, whatever be the Caufe of it, there is no longer any thing that refifts the Stroke of the Pifton which comes from the Heart, and therefore no Pulfation enfues. This is the true Reafon why the Arteries do not beat in that Part wherein they are cut. BUT becaufe the arterial Blood coagulates, as foon as it is out of its VefTels, that Blood which is diffufed between the Artery and the Part next it, muff needs grow hard and form a fmall Plug (as it were) that will flop the opening of the Artery; fo that the, Blood in the arterial Canal, ruffling againft that fmall Plug, runs quickly out a fecond time; and flowing to the Circumfer ee, occafions a kind of Noife or Whizzing which lafls till the Blood be upon the firft Coagulum, where it forms a feconrd Lay. Therefore, the more Lays of Blood there are one upon another, the greater will the Whizzing be. THE Blood diffufed in the fpurious Aneurifm, having no longer any Communication with the arterial Blood, ferments infenfibly within itfelf; tis Principles difunite at laft, it corrupts, and grows black, fo that the Skin tranfparent, a Membrane appears black and livid like the Body it covers. LATLY, 414 A 7A 1eatiJ of the SLMasLY, The hard Bodies felt in the fpurious Aneurfm, arc the Lays of coagulated Blood, which accumulate upon the Artery; and the Impoflibility of reducinig the Tumor arifes from the Bulk of it, and from thte Hardnefs of the extravafated Blood. THEA Prognoffic of the Aneurfmn, in general, is that the true one may fbmetimes laft very long, without any Neceffity of performing the Operation, and without any great trouble to the Patient, provided it be carefully kept down with CompreTffes fupported by a Bandage, and the Patient do not ufe any violent Motion: Nay, that Method alone will frequentJy cure the true Anreuri/n, as well as the fpurious, 6when there is no Extravafation. TiE fpurious Aneurifm is very dangerous, efpecially when the Effufion is confiderable; for, a Morrtification- and Gangrene are frequently the Confequencles of it; and the Operation cannot long be put off, without endangering the Life of the Patient. IN a Word, becaufe in the Aneurit/n occafioned by Phlebotomy, there is a Neceffity of tying the principal Trunk of the Artery; it follows that the Fore-arm and Hand being deftitute of Nourifhmenr, will be gangrened, unefs the collateral Branches can fupply it. Therefore, the Prognoffic of the Operationi muft needs be doubtful. It is more difficult to operate in the fpurious A4eu-rif than in the true, becaufe in the latter the Artery appears, as foon as the Skin is cut; but in the other, the Surgeon muft frequently take away firft abundance of clotted Blood, which gives him no fimall Troublk CHAP. IOpe z ons E S t R R Y. 4t7 CHAP. XLII. Of the Operation of the An*eurifih. T HE RE are two Ways of curing an Aneftf rfm, the firft is' the Bandage, which ought always to be begun with as far as the Diftemper will allow, and the fecond is the Operation. WHEN a Surgeon has the Misfortune to prick- art Artery, he ought, without being frighted, to have the Prefence of Mind of obferving the Orifice he has made: for if the Skin is cut parallel to the Artery, (which is known by the Blood's coming out freelyy without forming any Tumor in the Circumference of the Orifice) the Surgeon ought then to let the Patient bleed till he faints away: Upon which Fit the Blood flops of it felf, the Arteries have little or no Pulfation left, and the Drefling may be applied fafe. ly, without fearing the return of the Blood. IF on the contrary the Seaion of the Skin dbeg not direaly correfpond to that of the Artery, the Blood in gufhing out will firike againft part of the Skin; and being thereby refleted back will firead round the Orifice, and there form a fmrall Tumor, which will increafe in proportion to the Effiufon of Blood. In fuch a Cafe the Surgeon would do wrong in letting the Patient bleed till he fainted, bccaufe before the coming of the Fit, there would be fo great an Effufion, that the Surgeon would be obliged to proceed immediately to the Operation, and the diff'ufed Blood would Hinder the Bandage from prefling upon the Artery. Wherefore, as foon as it appears that the Opening of the Skin is not parallel to that of the Artery, the moft cffcaual Remedy is to flop the Blood. 41 " A7 eatfe of the TIIE firit Piece of the Drefling muft be a Papie chewed and well fqueezed: Brown Paper is beft: it muft be applied upon the fmall Tumor, before the Ligature be taken off, or upon the Opening, if the Patient has been fuffered to fall into a Swoon. Upon the Paper the Surgeon lays many graduated Compreffes,till he perceives that theirHeight is great enough for the propping Point of the Bandage to reft upon the Orifice, and outwardly upon the Cubitus. He bends the fore-Arm of the Patient that it may always remain in the fame Situation, by which means the Bandage will not budge, and then he takes a longitudinal Comprefs, which he conveys obliquely upwards' upon the Bending of the Elbow, and above the internal Condylus to pafs inwardly above the Compreffes, and makes a Circular in the upper Part of the fore-Arm. Afterwards, he makes the Bandage, which is the fame as that for Blooding, only with this difference, that the Surgeon ufes a much longer Band. THE Drefling being thus applied, the Patient having his fore-Arm half bent and fupported by the Scarf, muff be told not to flir his Arm at all. That Drefling is kept on three or four Days, unlefs fome fad Accident, fuch as a Mortification or an Hemorrhagy, require its being taken off fooner. THE Surgeon muft not be furprifeid, when, fome Hours after the Application of the Drefling, a confiderable Swelling happens in the Hand, and fbreArm: provided the Tumor be foft, though it fhould reach all along the Arm and part of the Back, and be attendad with an Inflammation, yet the Drefling bught not to be taken off. Nay, fometimes the Parts look blackifh; and then the Surgeon muft endeavour to know whether that Blacknefs be not a........certai Operations of S R G E R Y.. 4 f ceftain Sign of a Mortification (in which Cafe, thd Bandage fhould be removed) or whether it be ail Echymqofs. Thofe two Things are not then eafily diftinguifhed, unlcfs the Surgeon attends to the other Accidents which accompany the Blacknefs. I (lhall only obferve that the Echymofis, which is black at firfl~ grows yellow afterwards. WHeN there is no occaflon to take off the Bandage before three or four Days, the Surgeon takes it off then;-and if the chewed Paper flicks fill to the Opening, he muff not remove it, but on the contrary lay on again the Compreffes: and when he removes the Bandage two or three Days after, and the chewed Paper falls of itfelf, 'tis a good Sign. If any Drops of 'Pus come out then through the Wound, the Surgeon puts into it a balfamic and fpirituous Liquori and never any thing that is moift or oily. He advifes the Patient to keep himfelf quiet; and it is not improper to blood him two or three times in the other Arm. IF about eight or ten Days after blooding, there appears a Tumor as big as a finall Nut, attended with diftin6t Pulfations, &c. one may be fure it is a true Aneurifm, occafioned by the Opening of the Capfula or the Sheath, which contains the Artery, the Nerve, &c. SINCE I have fhewed above, that this Difeafe is a Hernia of the Artery, it ought to be minded with the fame Care as the Hernias, which happen in the Circumference of the Belly. Mr. 'Petit fays, that Hernias of all forts are frequently cured by Compreflion and Bandages; but they muft firft, be reduced. The Aneurifinal Tumor muff alfo be reduced before the Surgeon tries the Compreflion and Bandage and when he has reduced the Tumor, he does E c z 1ot 420 rA Teat;fe of the fiot remove his Finger from it, 'till the chewed Pafet takes its Place, and then the Comprcfkcs, &c. as I havre juft now laid. SINCE I have compared the Hernias of the Belly to thofe of the Arteries, I muff explain, by their Re-, femblance, the Accidents that would happen, if the Circumfiances above-mention'd were nbt minded; For hiflance, if in order to cure an Hernia, it vas not reduced before the Compreffes and Bandages art applied, 'tis certain, that Cotnpreflion would occafton a Gtangrene in the Parts, and all the Accidents, which I have -mention'd in their proper Places. The fame NVould happen in the Hernias of Arteries; for if the Redutirion of the Tumor was not miade before' the Application of the Bandage, its Comprefion being unequal, and throwing the Tumor more on one Side than on the other, the Arterr would open upon the leaft Effort, and a true Aneurifim wotuld become a fpurious one, which could only be cured by thc Operation,. whofe Succef' is not very certain. This, I know, has lately happcned; and when the Tumor burfied, Mr. Petit was fent for, and per. formed the Operation. MR. Thibaut faw a Man, who had (I know not upon what Occafion) a fmall Aneurifmal Tumor for the fpace of eighteen Years. The indigent Conditioni he was in obliged him to come to rParis, where he was taken up begging in the Sfreets, by thc Conftable appointed for that Purpofe. Thofe Men, when they fiz'e'd him, did fo much comprefs the Aneurifqal Tumor, that two Days after fo great an Effifflon happened in the Arm and fore-Arm, that the Patient was removed from the Hofpital to the Hatel-dieu, where the Operation was performed upon him; and it app-card that the firft Tumor was a fort of Ge//is which, Operations of SUR n R Y. 421 which had refifted the Force of the Heart for the Spacc of eighteen Years. SOME Steel-Eandages to be found in the Shops of Trufs-makers are alfo recommended for the Comiprelion of thofe Tumors. Their Ufes are alfo.approved by the beft Surgeons; but they ought to begin with the Bandage which I have juft now defcribed. IF the firft Method of curing Aneurifmss has not been as fuccefsful, as was expcted j but on the conT trary, thie Aneurifm is very much encreafed; or is become fpurious; or if the Effufion, in this latter Cafe, threatens; Gangrccn, the Surgeon muft proceed to the Operation; and in order to it, three effential Circumnftances ought to be carefully attended. The firft is to prevent the Effufion of Blood during the Operation; the fecond, to lay open the Artery and the third, to make a Ligature upon it. THE Blood cannot well be kept in but by come prefling the Artery with the Help of a Noofe and Tourniquets but becaufe in that Difeafe the Arm fre, quently lofes its ufual Figure, by an extraordinary Swelling, it is requifite to know which is the moft proper Place to apply thofe Inftrumenvs in iuch a manner that without occafioning any Diforder, they may, on the contrary, anfwer the Surgeon's Inteition. THAT Place iS Of two Sorts, either of Choice or Neceflity. The Place of Choice is always in the internal and middle Part of the Arm, and not lowcr, that there may be at leafi four Fingers between the Comprefs and the internal Condylus, becauf'e the Surgeon is frequently obliged to go on with the In, cifion as far as that Place, in order to take out the Clods of Blood, and relax the Skin. THE Place of Necciity isobvious by the Sweling 4f the Armi for the Blood whi h is xun back, as 1 E c 3 have 41% A Treati~fe of the have explained it above, would not only hinder the Ligature or the Noofe from comprefling the Artery fufficiently, but alfo might bruife the Parts upon ivhich it is applied, and occafion a Gangrene. Wherefore to avoid a great Pain, and the fad Confequences already fore-feen, the Surgeon has recourfe to the Place of Neceflity, lying under the Arm-pit, where he lays a pretty thick Comprefs, that he may the better tie the Veffels, and of a round Figure, that it may lie conveniently in the Hollow of the Arm-pit, and not bear hard upon the great pedoral Mufcle, and the latijjimus VODrf, nor bruife them, and that by fuch M ans the Compreffion may be direfly upon the Veffels. Above that round Comprefs the Surgeon applies a longitudinal Comprefs, which runs crofsways upon the Shoulder. Afterwards, he turns the Ligature twice over that Comprefs, and ties it upon the Shoulder with a fingle Knot, and a Loop. He conveys over the Shoulder, betweeu the Ligature and the Comprefs, a round Piece of PafteBoard or Horn, that the Torniquet may not hurt the Skin, e&c. IF the Surgeon ufes the Tourniquet in the middcl Part of the Arm, which is the Place of Choice, he muft firft of all lay a long, narrow, and very thick Comprefs upon the internal Part of the Arm, upon the croffing of the Veffels. He fupports it by another long Comprefs in three or four Doubles, and conveys the Ends of it one over the other in the internal Part of the Arm. Laffly, he lays the Ligature and the round Piece ofPafte-board, as I have already faid. THREE Circumftances ought to be obferved, in r-der to apply the Noofe well. Firft, the Touniqut to turn but once or twice at moft, in order to f#oi:) Operatios of SURGER Y. 423 flop the Blood. Secondly, the Tourniquet muft be applied in a dire2 oppofition.to the Veffel, as welt as the round Piece of Pafte-board, Leather or Horn. Thirdly, the Knot muft be turned towards the hind Part of the Arm, that it may not be in the way of the Servant, who holds the Tourniquet. THE Operator being very much embaraffed by a great number of Servants, we are extremely obliged to thofe who enable us to operate with few Perfons; and therefore I cannot forbear obferving here how much we are indebted to Mr. Petit for inventing a Tourniquet, which has all the Conveniences of the other Inftruments, and none of their Inconveniences, as I fhall ihew, when I come to difcourfe of Amputations. To obferve the fecond Circumftance, which confifts in laying open the/Artery, I fuppofe the Patient to fit upon an Elbow-Chair, towards the Light. The Apparatus being ready, and the Tourniquet well placed, the Surgeon bids a Servant itreighten the Noofe in order to.comprefs the Artery, and nakes an Incifion upon the Tumor, which affefs only the Skin at firft. That Incifion ought to be made i1 fueh a manner as to begin in the middle of the foreArm and the Inftrument is conveyed obliquely towards the internal Condylus of the Humerus. AUTHORS advife the Ufe of a Lancet for that Incifion. Mr. Arnaud and Mr. Petit fay, that Infirument fhould never be ufed, when the Surgeon has a mind to avoid offending fome Parts, and is afraid of fomething; and therefore they prefer the Biflouri, becaufc an Operator well skillcd in handling that Inftrument can fee what he cuts. AFTERWARDS the Surgeon makes fmall Incifions with a Bifouri in the fatty Body: and when he perE e 4 ceives. 424 A 7Aeatife of the.eives a fmall Clod of Blood, he may be fure the CyfJis is open; and then he introduces a Finger into it, and over that Finger he conveys crooked and blunt Scizars to make an end of the Incifion. IF that Incifion does not appear fufficient to take pff all the coagulated Blood, Mr. Arna2ud advifes one to, make another from the middle of the firti to the hinder Part of the Arm. This fecond Incifion is very ufeful; for it affords more room to evacuate the Blood and wipe the Wound, befides it relaxes the Skin very much; which is no fmall Advantage, fince the Skin frequently makes a greater Conflritiqon than all the other Parts. W ix.E all the Efffiion is thus expofed to view, the Surgeon perceives two Sorts of Blood; one, that is only half coagulated, the molt fuperficial, and the laft that came out of the Artery; the other to be (e'n next is like a Coagulum, and in Lays, as I faid before, that are harder as they lie nearer the Artery. Afterwards, the Operator takis off the Clods and Lays of Blood, with a Flearn or Myrtle Leaf, till he fees the Aponeiroqfis of the Biceps: Then he bends a little the Patient's Arm, to relax the ApoNeuroffs, and introduces under it a Stilet or a grooved Probe, over which hlie conveys crooked and bent ScifTfars to cut it in the Place of its Infertion, and then he raifes it, and cuts it about its Original; and by that means he relaxes a confiderable Conffriaion occafioned by Pit; befides, that it is a great Hinderanct tQ the Operation by concealing all the Veffels. THERE are ftill under that Aponeuro/iq fome Clods pf Blood, which muft be taken off, efpecially that which came out firift, and which being moulded in the Figure of the Orifice, corks up, as it were, the Artery. That Clod, tho'the nearpit to the Artery, is tehe Operations of SURG ERY. 41 j the firft that comes out, as I have already faid; and being of the oldeft fianding, it muft needs be the hardcft. Laftly, when the Surgeon has cleared the whole Tumor from the fcveral Lays of Blood, he relaxes the Tourniquet a little, that he may eafily fee the Opening of the Artery, &cc. THE third Circuniftance to be obferved in that Operation, confifts in preventing the Artery from emitting any Blood thro' its Opening; and therefore our modern Operators ufe the Cauftick, or the Ligature. If the Cauftick be refolved upon, Mr. Arnaud's Pa6ticc is as follows. As foon as the Orifice of the Artery is layed open, he takes a Piece of fine worn out Linncn; he dips it in a liquid Cauffick, which he prefers to all others; he fqucezes it, left any Drops ihould get into the Cavity of the Artery; afterwards, he applies it diredly upon the Orifice of the Artery, and over that fmali Tent he lays a fmall Comprefs, and round about dry Terebinthine, or Colophony. Over that Comprefs he lays another fomewhat larger, and bo on, till they rife to a proper Height, taking care to keep always his Fingers upon the comprefcfs. He takcs off the Tourniquet, and makes the Bandage, as I flhall hew hereafter. I fhall only obferve by the Way, that Mr. Tetit in all the Operations never ufes dry Terebinthine, Colophony, or any Aftringent for fome Reafons, which I flall mention, when I come to difcourfe of Amputations. THAT Dreffing is kept on five or fix Days; and when the Surgeon has a mind to take it off, he muft always have a Tourniquet ready. He loofens the Ligature, taking Care always to prefs the Compreffes.with his Fingers. He takes them off one after anather, 4x26 A Treatile of the ther, and does not touch the laft, till they fall off themfelves. Suppuratives or Ointments muff never be ufed, but the Dreffingsare to be performed dry with the Compreffes, Dozels, &c. WHEN the Compreffes and the finall Rag are off, the Surgeon perceives in the Artery a whitifh Place, where the Pulfation is more fenfible. That is, the Place where the Divifion was: It muft not lie uncovered long; but the Surgeon muff fpeedily apply upon it a pretty hard Dozel, firowed with Powder of dry Terebinthine, &c. in order to produce good folid Flefh about the Artery, and then lay s the Remainder of the Dreffing, as I have faid above. THE Patient's Arm muft be bent in fuch a manner as to reprefent only a blunt Angle, fupported by the Scarf, and leaning upon a Pillow. The Patient muft be blooded more or lefs, according as the Accidents require it; and he ought to obferve a firiat Diet. WHEN the Operator refolves upon the Ligature, which is now moft in ufe, becaufe Surgeons are perfuaded, that tho' the Artery be tied in its Trunk, yet the Arm lives fill, fince it receives Blood from three Branches, which iffuing from the Trunk out at three Branches open into the interoffous Artery, and the two others into the radial and cubital; I fay, when the Operator refolves upon that Operation, he bends a little the Patient's Fore-arm to relax the Veffel. Aferwwards, he ufes a fquare Herina, which is better than a crooked one. It muft be blunt; and the Surgeon introduces it into the Orifice of the Artery. He raifes it % little, holding the Herina with his left Hand; arad with his riglht he takes a fharp B~jrouri, with which he diffec&s the Artery, and divides it from the Nerve and Vein attending it, when there Operatons of SUR GER Y. 417 is room under the Artery, the Operator puts in his Herina and he raifes it, and diffets a little above and beneath the Opening, but as little as poffible; and then he paffes into it a crooked Needle, threaded with a wixed Fillet, made up of four or fix Threads, as I have explained it, fpeaking of Sutures. MR. Arnaud advifes one to pafs that Needle under the Artery, with the Head firft, for fear of pricking it with the Point, to pafs only one half of it, and bid a Servant hold it in that Situation, left the Edges of the Needle fhould cut the Artery: And in the mean time the Operator muff draw the Threads fufficiently to hold in the middle on one Side; and on the other he muft withdraw the Needle. MR. 'Petit has invented a Needle, which is neither fharp pointed, nor very blunt: It has no Eye at the Head, but a fmall handle which ferves to hold it mnore fafely: It is crooked, without Edges on the Sides, or the Edges are very blunt, and it has an Opening in the middle to pafs into it the waxed Fillet fo that with that Inftrument, the Operator can pafs the Thread under the Artery, and withdraw the Needle, without pricking or cutting the Artery. HE cuts the Fillet in the middle with a pair of Scifars to make two Ligatures out of it, one of which he conveys over the Orifice of the Artery, and the other under it. Afterwards, he lays a fmall LinnenRoll upon the Artery which reaches from one Ligature to the other, he makes at firft a fingle Knot with the upper Ligature to tye the Artery hard, and above it a double Knot; and then he unbraces the Tourniquet, to fee whether the Artery be well tied, which he knows, when no Blood comes out: Afterwards, he cuts thofe Threads at fiv Inches diftance from the Artery. He does the fame in the loweft Ligature to flop 4tg A Treate of the fap the Blood, which difcharges it feif into the rec maining Part of that Veffel through many fmall Branches falling into the Artery, as it appears, not only by Inje&ions, but alfo by the Operation; for, when thofe Ligatures are made, if the Surgcon unbraces tlie Tourniquet, he feels the beating of the Artery under the lower Ligature. This Mr. Petit made nime obferve, when he performed an Operation of the A4neurfm. Mir. 4rnaud and Mr. Petit have obferved, that when they had diffeaed the Artery, as I have juft now faid, there was always fonme Blood upon the Drefing, which could only proceed from fmall collateral Veffels, that were cut, and were fo fminall in the time of the Operation, that they could not be obferved; hut being infenfibly dilated by the great Quantity of Blood conveyed into them, they became very confiderable, and afforded a great deal of Blood. In order to avoid that Accident, thofe Surgeons do not 4iffeit the Artery: they only take care to feparate the Nerve from it; and then they convey the Needle under the Artery, taking with it the Flefi, and not the Nerve; and if a Surgeon ufcs Mr. Petit's Needle, he draws one End of the Fillet on one Side, and the other End with the Needle on the other. He makes under the Orifice of the Artery, a fecond Ligature in the fame manner; he cuts the Thread in the Mliddle; lc lays on the fmall Boll of fine Linnen, and the ref, as I have faid. WRjA T remains is to lay on the Drefling, which I would not encumber with many Tents, as 'tis generally praaifed, being perfiuaded that the Ligatures above defcribed are fuifficient to flop. the Violence of the Blood, and that a great Number.9f Dozels, and fniall Comprefks heaped up Qnq upor: Ope.ations of SR GERY. 419 upon another, to fuch a Height as is reqnired, do fo prefs all the internal Veffels, and extetnal Bandages, that the Blood of the Veins remaining in the foreArm without Motion, and the Arteries affording none any longer (becaufe the Preflure of the Tents hinders the friall Branches of the Artery from dilating, and affording Blood to the interoffous, radial, and cubital Arteries, as'I have faid) the Mortification of the foreArm muff enfte, which happens but too frequently. I would therefore drefs that Wound with a fmall Comprefs, narrow, and fomewhat long, to be applied all along the Artery; and I would put about that Comprefs fome foft Dozels, and upon the Whole fome plain Lint, without making any Plagets or Dozels of it. The Surgeon thould cover that Dreffing with a fmall fquare Comprefs in three or fotr Dot*bles, and dipt in Brandy: and above it a fimpkt one longer, and dipt in Brandy, with which he makes tWo Circulars, one in the lower Part of the Arm, and the other in the upper Part of the fore-Arm. He covers again thofe Compreffes with a longitudinal one, which he paffes obliquely upwards, over the upper and fore-part of the Radius: He conveys it obliquely above upon the Fold of the Elbow, and under the internal Condylus, to pafs inwardly above the Compreffes, upon which he always keeps his Fingers, and to make at laft a Circular in the upper Part of the fore-Arm. THE Bandage proper to contain that whole Dreffing, is the fame as for blooding, but the Lift ought to be much longer. When that Lift has been ufed, the Surgeon applies a longitudinal Comprels all along the internal Part of the Arm> to comprcfs the Artery a little; and he fupports that Comprefs with Edgings made with another Lift rolled with one Head. He begins 430 A Treatife of the begins to apply the laft Lift about the middle Part df the fore-Arm, and conveys it as far as the Shoulder. Before the Surgeon begins thofe Bandages, he muft place the fore-Arm in fuch a manner as to make a blunt Angle with the Arm. AFTERWARDS, he fhall cover the whole Arm with large Cloths dipt in warm Wine, wherein Braindy is predominant. The Arm muft be kept iu a Sling, becaufe it frequently happens, that thofe Patients falling into Convulfions, ftrctch out their Arms, and break the Artery. Of the Triangular Scarfs IT is eafter to make the Bandage, called the Triangular Scarf, with a fquare Napkin, than with a long one; yet becaufe the latter is more common than the other, I fhall give a Defcription of it. THE Surgeon takes the Napkin with his left Hand by one of the Angles, and leaves it thus hanging: Afterwards he takes, with his Thumb and fore-Finger of his right Hand, the Angle neareft to him, and bringing it near that which he holds with his left Hand, he conveys it, fliding upon the Hem, till it can defcend no lower. I fuppofe the Operation to have been made on the left Side. The Surgeon fhall place foremoft the Angle of the Napkin, which he holds with his left Hand, upon the right Shoulder ' and thofe Parts of the Napkin, which he holds with his right Hand, fhall be oppofite to the affcaeSd Elbow. Having thus applied thofe two Heads, he bids a Servant hold the Head, that is upon the right Shoulder, and the Surgeon raifes the oppofite Head, which hangs down, to cover the fore-Arm with it, and to convey it upon the left Shoulder, that he may Operatfons of S U R GF, R YO 431, inay afterwards tie it upon the right, togethtr with that which was firif applied there. What remains, is only to fold and hide the End and the uneven Parts: of the Napkin, to be found in the hinder Part off the Arm, add to pin them: which makes a very con" venient and neat Bandage. AFTERWARDS, the Patient lies'upon his Backi and they put a Pillow by him to lean 'his Arm uponl. Care is taken to lay over that Pillow a waxed Cloth, that it may not be imbibed with the Ipirituous and hot Fomentarions, with which the whole fore-Arm and Hand are to be hourly moiftened Night and Day, taking care to lay over the whole a Sheep's Skinwhich muft be warmed every time. ALL thofe Precautions do fuflicintly ihew, that the Surgeon's Defign is to preferve artificially the Heat if the foreArm, as much as ppflible, till Nature finds out a way to diffuife into it that precious Liquor, whofe Paffage we have obifrudted, and which cannot be long abfent without the Lofs of the Member. THE Surgeon ihall frequently examine the Hand, fince the Condition it is in makes him judge-of the Event of the Operation; and among all the Signs which I have mentioned, lie muff know that the Pulfe is not felt at the fooneff, till four and twenty Hours after; and it frequently happens that he docs not perceive it for three or four Days. Howevcr, he muff not infer from thence that there is a Mortificaiion, ftnce notwithifanding thefe Accidents the Hand may hlill enjoy a Life common to.the whole, as it appears from the Heat of the Part. IT is alfo proper to leave the Tourniquet Ioofe during four and twenty Hours, that it may be ufed upon occafion; far if the Blood fhould come our, a Ser*ati or the Nurfe, might brace the Tourniquet,. wh iI 43Z ATreatt/e of tibo whilft the Surgeon is fent for. -But if he was at a great diflance, and could ndt come foon enough, the Ufe of the Tourniquet would be dangerous, becaufe it deprives the Arm of Nourifhment and Senfe by its ftrong Compreffion: and therefore it were better for the Servant to lay his Fingers upon the Artery, in order to flop the Hemorrhagy. To remedy there Accidents, Mr. Arnaud leaves always a waxed Fillet under the Artery, that it may be ready at Hand to make a Ligature fomewhat higher upon occafion. THE Wound is dreffed every Day much in the fame manner as I have laid, by ufing a Cauffick, that is, by letting fall the Comprefs lying upon the Artery, and the Dozels alone, and imbibing the whole Drefling with warm Brandy; and then the Surgeon applies fome Plagets covered with a Digeftive, &c. THE Patient is blooded in the other Arm, more or lets, according as the Accidents require, and according to his Strength. He takes a Clyfter every Night, and keeps a ftrit Courfe of Diet, that is, he takes only Broth every three Hours, and now and then fome Spoonfuls of Jelley. IF that Operation be performed for a true Anedrifm, the Surgeon muff go about it in the fame manner; but he muff open the Tumor with greater Caution, cut the fat Body gently, and even tear it, as in the Operation of the Bubonocele: and as foon as he perceives the Bag, he conveys, with its help, upwards and downwards a grooved Probe, to cut with a Razor or a Bifouri what lies upon the Groove, and to enlarge the Opening by that means. And when the Hernia of the Artery lies open, he divides the Nerves from the Artery, as in the fpurious Aneurnfm, and makes a Ligature above and under the Tumor, in the Operations of S UR G ~ R Y. 433 the manner above defcribed. Afterwards, lie dpens the Bag, according to the Length of the Artery, to let out the Blood contained in it; and then he unbraces the Tourniquet, to fee whether the Blood be well flopped, and dreffes the Patient after that Operation, as I have fhewed, fpeaking of the fpurious Aneurrfm. CHA P. XLIII. Of the Wounds of the Tendons in relation to their Sutures. T HE Tendons, as well as all the other Parts of the humane Body, are liabfe to be cut, torn, pricked, or bruifed. THOSE different Solutions of Continuity, which happen in the Tendons, do generally proceed from external Caufes, fuch as bruifing, or fharp Inftruments, or Falls; yet they may be occafioned by Fratures; for a Splinter of a Bone may cut, tears or prick a Tendon. THE Accidents arifing from the Wounds of* the Tendons are very difmal, and differ according to thd different Solutions of Continuity. For Inftance, if the Pain of a Tendon, either pricked or torn, is very great, and even threatens Death; and if, according to the Advice of all good Surgeons, the Tendon be cut off; then all the difmal Symptoms vanifh, and the Patient finds himfelf eafed: Which lhews, that among all the Indifpofitions of a Tendon, the total Seaion of it is attended with the feweft Accidents, F f O 'I 434 ATreat'fe of tfe On the contrary, when a Tendon is torn, or half cut, pricked or bruifed, the Patient is affeaed with) violent Pains, a continual Fever, a 'Delirium, Convulfions, and other dangerous Accidents. A Tendon being a very ftiff and diftended Organ, is liable to the leaft Concuflfons, and confequently its Wounds muff needs be attended with fharp Pains. AND becaufe the remaining Fibres of a Tendon, that is half cut, can make but a weak Refiftance to the violent Contra&ion of the Mufcles, fince they have loft thofe Fibres, which helped them to refift, there muft needs be a violent and frequent Reflux towards the Brain, attended immediately with a Return of the Spirits into the wounded Part, which occaftons violent Pains; and they will encreafe as the Drawing becomes more confiderable. THE more the Pains encreafe, the greater is the Reflux of the Spirits, and their Motion growing thereby very rapid in the Brain, muft needs be alfo vehement in all the Parts of the Body, and by a neceffary Confequence thofe irregular Spirits putting the Blood into a great Motion, muff occafion a Fever. The Blood being agitated, as we fuppofe it to be, may produce very bad Symptoms; and they may eafily be accounted for by a Surgeon never fo little acquainted with the Mechanifm and Ufe of the Parts of the Humane Body. THE VDelirium and Convulfions depend alfo upon the irregular Motion of the Spirits, which is a Confequence of their violent Reflux from the wounded Part to the Brain. IF the Tendon be pricked, the Pain is felt not only in the Solution of Continuity, but alfo in very remote Parts. TOR Operations of SUR GER Y. 43j FOR Inflance, if the Tendon of the Profundus Inflexor of the Fingers, is pricked at the Fingers End, the Patient will feel a Pain all along the Hand and Fore-arm, as far as the internal Condylus of the Humerus, from whence that Mufcle proceeds. And becaufe the Inflexors of the Fore-arm are inferted near the Original of that Mufcle, 'tis plain it will communicate to them its Inflammation; which is the Reafon why the Patient feels a Pain in the Shoulder and under the Arm-pit, and why the Glands of that Parts fwell, and are apt to form an Abcefs. WHEN the Tendon is bruifed, the Blood and the Lymph, which diffufe themfelves into the infide internal Parts of the Fibres will ferment, their Salts will difentangle themfelves, and grow more grofs, and confequently will be more capable of irritating the tendinous Fibres. And becaute I have faid, they are very fufceptible of a fhivering Motion by reafon of their Diftenfion, it follows that the Pain and the infuing Accidents will be confiderable in the Contufiion of a Tendon. THE Prognoftic of the Wounds of the Tendons in general is very bad; and the Fever attending them is not only very dangerous in it felf, fince it occafions all the Symptoms that proceed from the great Agitation of the Blood, but is alfo very pernicious to the Wound, becaufe that Part grows thereby more fenfible, and the Humour which at that time extravafatcs in the Part, being alfo more ferous, becomes more acrimonious and corrofive. IT may be further added that the Prickings of the Tendons are frequently attended with an Abfcefs ini the Parts remote from the Illnefs, as I fhall fhew, by fome Inflances, when I come to difcourfe of the RPanaris, and confecqucntly they are very difmaI, Ff1 f 436 A Treat'fe of the As for what concerns the Cure of thofe Difea' fes, the Ancients thought the Tendons could not be re-united, becaufe, faid they, thofe Parts, are fpermatick; and carried away by that Paradox, they maintained the Wounds of the Tendon of Achilles to be mortal. But thofe Parts being nourifhed with Blood, as well as all others, and the Bones and Cartilages, though more folid, being capable of Reunion, it neceffarily follows that the Tendons are alfo capable of Reunion. Many Pratitioners have cured the Wounds of the Tendon of Achilles; and Mr. Thibaut made a Suture in it at the Hotel-dieu, when it was wholly cut off; and that Suture had good Succefs. Mr. CQofe, Sworn Surgeon of Paris, heretofore Mafter of his Company, and Demonftrator of Anatomy, told me he had made it feveral times, and that it always fiicceeded. The following Inflance confirms this Opinion, and proves undeniably that the Wounds of the Tendon of Achilles are not mortal. A Man falling into a Sink, near the fmall Stalls, mot far from the Baftile, his Foot flipt: he felt immediately a great Pain in his Heel, which was quickly attended with a confiderable Inflammation, without being able to walk, or lean upon his Foot. The Surgeon being fent for applied emollient and foftening Remedies, as the Indications feemed to require, without forgetting to blood the Patient; but the Accidents encreafed inftead of leffening. Whereupon the Patient four and twenty Hours after, fent for Mr. Poncelet, fworn Surgeon of Paris, heretofore Mafter of his Company, and Demonfirator of Anatomy and Surgery, who having obferved a fmall Tumor, opened it immediately: A little Blood came out of it. That Tumor was hardly opened, when he perceived OperevtIo;s of S U R G F R Y. 437 Perceived the hinder Part of the Cd!ýcandllu fra~lured; and becaukc' the Piece fhook, he cut the Tendon of Achi les adhering to it, and pulled the Piece out. After the Exfoliation of the Tendon, and the Cure of the XVound, the Paticnt walked as well as if that Tendon had not bect cut. WVHEN the Tendon is half cut, arnd the Accidents above-mcntion'd are not yet violent, Mr. 'Duverney advifes to cure that Wound with the falfam of Fio, ravanti and Coplahu, and the Oil of Eggs mixed to, Xgether. THE Patient muff be blooded three ot four times, without any delay; he muff take Juleps and foftening Clyfters; and if all thofe ReMedies do not leffhn the Accidents, the S urgeon muff refolve to cut the Tendon; and when the Fluxion is very much lefThned, he nmfI make the Suture. IF the Tendon is wholly cut, the making of the Suture is thought to be a fovereign Rercdy. But that Rule is liable to fome Exceptions: for in fome Cafes that Operation is altogether impoflible; in others, it is poffible, but dangerous: Lafily, upon fore Occafions it is of no manner of Ufe. When a Tendon, that is cut, has loft a great deal of its Subfiance; when the Ends of it have confiderably withdrawn themfelves into the Flefh, and 'tis impoflible, by difintangling them, to bring them near one another; the Fridions which Surgeons advife to be made downwards upon the Body of the Mufcle, arc of no great Ufe. Mr, Petit Lays, That Method feems indeed to have a good Effed upon a Corpfe, but that it has not the fame Succefs upon living Blodies. When therefore, by reafon of a great LofS of Subtlance, the Ends of a Tendon cannot bc brought together, the Operation is iimpofible. E'fs DiOUGHVG 438 A Teatife of the THOUGH the Ends of a Tendon, that is cut, may come near one another, yet it ought to be obferved, that if they are bruifed, the Suture would occafion fuch fad Accidents, that the Surgeon would be obliged to cut it; from whence it appears, that the Operation would prove dangerous. On the contrary, in fuch a Cafe, a gentle Suppuration ought to be excited, as I fhall fay hereafter, and when the Inflammation and Contufion are diffipated, the Suture may be tried. THE Extenfors of the Fingers being very flat, and their Teguments being clofely united all along their Progrefs with the PeriofJeum, of which they even feem to be formed, it appears by that Stru6ure, that if the Tendons happen to be cut tranfvertly, the inverfe Situation of the Hand is alone fufficient to make them grow together again, and confequently, that in fuch a Cafe, the Suture is very ufelefs, as well as in the Flexors of the Fingers, and the Extenfors of the Toes. The pricking of a Tendon being a very fmnall Wound, which occafions dreadful Pains, very fad 'Accidents, and great Inflammations, the Relaxation muft be tried with foftening Remedies: Blooding is of great Ufe to that End, and likewife cooling Juleps and Potions. The Topical Remedies ought to be moiftening and fpirituous mixed together and the Surgeon muft take care to keep the Wound open, till all the Accidents are over, and inflil into the Wound fome Balfam of Fioravanti and Copabu, mixed together with Oil of Eggs: And if the Accidents continue, the Tendon muff he cut a gentle Suppuration muft be excited, and a Suture made, when the Acutencfs of the Pain is over. L iATLY, if the Tendons are bruifed, the Surgeon mnuf Operations of SU GER Y. 439 muff uncover them, and excite in themf gentic Suppuration; which is eaffly perceived, becaufe when they exfoliate, they come out like Flax. And if notwithfltanding all thefe Precautions, the Accidents encreafeinftead of leffening, the Tendon muft be cut, and when the bad Symptoms are over, the Surgeon makes a Suture. CHA P. XLIV. Of the Operation of the Suture of the Tendon. HAT Operation being ufually performed upon the Extenfors of the Fingers, when they are cut in the upper Part of the Metacarpium, or upon the Wrift, Mr. Adrnaud advifes one to cut the annular Ligament in order to look for the Tendon. IF two Tendons are cut, and fhrunk, as it always happens, becaufe the Patient bends his Fingers immediately, that Situation being more convenicnt; the fame Surgeon advifcs one to firetch out the Hand, and to make, with a very tharp Biflouri, a fmall longitudinal incifion in the Skin, direaly between the two Tendons, without hurting them, or taking off their Cover, which is the beft Plaifter that can be applied upon them. Afterwards, the Surgeon endeavours to bring both Ends together, by firetching out the Hand very much; for, I think, it is the only way of doing it. MR. RPetit advifes one not to remove the Tene dons, if poflible, from the adjoyning Parts; but if Ieiir Divifion was fo old, that they were grown F f 4 callous 440 S A Treat'fe of the callous at their Extremities, and adhered to the neigh' bouring Membranes, the Tendon ought then to be feparated from them a little, but not towards the Skin, as I have already faid, and the callous Extremities fhould be cut, to open the tendinous Fibres, that they may let out the nutritious Juice which is to reunite them. ALL the Moderns advife one to take the End ofaTendon, that is cut, with fmall Pincers, armed in the Infide with fmall Teeth, the better to take hold of the Tendon, and a Ring to ftreighten very clofe the Branches of the Infirument, that are to pinch; and then to draw the End of the Tendon in order to bring it near the other End, and holding the Forceps with the other Hand, as I fhall fay hereafter. MR. Petit does not approve this Praftice: He fays, it may bruife the Tendon to fuch a degree, that it will occafion an Inflammation, and confequently a great Suppuration, which taking off a great deal of the Subftance of the Tendon, will prevent its Reunion. On the contrary, he advifes one to pierce it in the Middle, together with the Skin, without altering its natural Situation, without Pincers, and then to firetch out the Hand, in order to bring the two Ends together. ALL thefe things being duly obferved, the Surgeon fhall proceed to the Operation. But becaufe the Needles he muft ufe, are very fmiall, and the right Hand could not drive them fafely, and at once into the Skin and Tendon, without fhaking, nor the left Hand fupport the oppofite Part, the Operator ought to ufe additional Helps proper for both Hands, viz. the Port-needle, and the fmall Cannula, as I obferved, when I dif(ourfed of the Hare-lip. N EEDLES for the $uture of a Tinion muff have quite Operations of SURGE RY. quite another Figure than for all other Sutures, that they may not deftroy the Fibres of the Part. Firft, they muft be crooked, becaufe 'tis an eafy thing to withdraw thofe Sorts of Needles. Secondly, they muft only be fharp in their concave Part to feparate only the Fibres of the Tendon, wherein they differ from the Needles for the Sutures of the other Parts, which are fharp on the Sides, and cut the Fibres on the Sides. Thirdly, their Eye muft correfpond to the Edges of the Needle, that is, lye on the Side of the concave and convex Part, that the Bulk of the Thread may not make the Wound gape, and that the Needle may pafs more eafily. WHEN the Operator has got a proper Needle, it muft be threaded with a double and waxed Thread, forming a Loop in the Middle. Afterwards, he will infert that Needle in the Port-needle, furrounding firft the Head of the Needle with a fine fmall Rag, or a Piece of Paper, that it may not waver in the Grooves of the Port-needle. And, as I have already faid, difcourfing of the quilted Suture, that the firft Stitch ought to be made at the Extremity of the Mufcle, oppofite to the Origin, becaufe it fhrunk in more; here we muft ufe the fame Precaution, and pierce firft the End of the Tendon oppolite to the Origine of the Mufcle, becaufe it fhrinks moft. THE Surgeon holding in his right Hand the Portneedle, armed with the Needle juft now defcribed, fhall pierce the Skin and Tendon, at the fame time, from the Outfide inwards, and about two Lines from the Extremity, fecuring the Part with the Thumb and Fore-finger of his right Hand, or holding in that Hand the fmall Cannula, which I have propofed as a Help. Afterwards he thall loofen the fiall Ring of the 44t 4 Treatife of the the Port-needle, to leave the Needle free, that he may draw it by the Point, holding the Thumb and Fore-finger upon the Skin on both Sides of the Tendon. The whole Thread muft not pafs through the Wound, which the Needle has made; but the Surgeon muff put in the Loop which we have left in the Thread, a fmall Peg; confifting of a Piece of waxed and rolled Taffety; for thofe forts of Wounds require Pegs to prevent the Thread from cutting the futured Parts, becaufe the Lips of the Divifion are naturally apt to keep afunder. WHEN the Operator has brought the fmall Peg near the Skin, by drawing the Thread, he puts the Needle in the Port-needle, and paffes it through the other End of the Tendon from the Infide outwards, taking the Skin with the Tendon, and ufing the fame Precautions. Afterwards he adapts the two Ends of the Tendon in fuch a manner, that one of them may pafs over the other; and then he keeps the two Threads afunder to put between them a fecond Peg of waxed Taffety: he makes a fingle Knot, and a Loop over it. THE waxed and rolled Taffety is more proper than Linnen, becaufe it is firmer, and makes a greater Refiftance, though it be pliant, and capable of affuming the Figure of the Part; aud laffly, becaufe it does not imbibe the Pus that comes out of the Wound, and therefore will occafion no Eryfpelas, as I obferved, when I difcourfed of the qpilted Suture. THE Surgeon pours upon the Wound fome Drops of a fpirituous Balfam, and puts between the two Pegs a Plaget dipt in the fame Balfam, and over the Whole, a Comprefs dipt in Brandy, faftening the Dreffing with-two or three Circulars of a fmall Lift. THE Operations of SuRGER Y. 443 THE Surgeon always takes care to keep the Hand ftretched out during the Dreffing, and makes an Embrocation upon the whole Limb, efpecially all along the Mufcles whereof the Tendons are cut, and towards the Origin of the Nerves, which enter into them. The following Embrocation appears to me very good. TAKE an Ounce of Worm and Fox-oil, an Ounce of Man's Fat, and half an Ounce of Wormsjuice: mix the whole together: Warm, upon a Plate, as much of it as you pleafe: Add an equal Quantity of Brandy to it; and rub the Limbs with it before a fmall Fire. Do this three or four times a Day, while the Pa: tient is under your Cure, and cover every time the Fore-arm with Comprefies dipt in warm Wine. Now the Fore-arm and Hand muft be put into an Engine, that will always keep the Hand tfrctched out. Mr. Arnaud has invented one of Tin: It is made like a Gutter, and contains the whole Forearm. In the place of the Elbow there are two Notches, one on each Side, to lodge the Arm, that the Engine may equally ferve for both Arms; but on the Side of the Hand, that is, a Finger's Breadth beyond the Wrift, there is a Hinge, to which is added a Plate of Metal, with the Help of a Peg, which goes into the Hinge. That Plate makes an Angle more or lefs obtufe with the Gutter, with the Help of two Hooks, one on each Side, which from the Plate wedges in the Holes upon the Edges of the Gutter; and by that means the Fore-arm is lodged in the Gutter, and the Hand is ftretched out upon the Plate, which muft be a little longer than the Fingers. And becaufe the Patient might ftill bend his Fingers, they have engraved in the Middle, and on both Sides of the Plate two Chinks, through which they pafs a Fillet, 444 A Treat'fe of the Fillet, which firaitens and brings the Fingers near the Plate. But if the Suture had been made in the Extenfor of the Thumb, it were needlefs then to keep all the Fingers in the Stocks, when only one of them is difordered, and therefore to avoid that Fault, the fame Surgeon ufes a fmall Plate narrower than that I juft now defcribed, and notched on the Side of the Fingers, that they may eafily bend. To make a good ufe of the Engine, the Surgeon puts into it a Lay of Oat-ftraw, adapted to the Figure of the Arm; and a fmall Cufhion of Oat-ftraw upon the Plate, and then places the Fore-arm and Hand upon the Drefling. Afterwards he covers the Hand and Arm with Compreffes dipt in warm Wine, and fupports the whole with feveral Lifts, about the Engine and the affe&ed Limbs. IN proportion as the Wound cicatrizes, the Surgeon fhall lower the Plate, by means of the Hooks, and continue to ufe the fame Ligament, without putting fo much Brandy into it as in the Beginning. He ihall gradually give fome fmall Concuffions to the Part, rubbing it with the warm Liniment, that the Tendon may grow pliable, and lengthen by degrees for without fuch a Caution the Part would be in Danger of being always bent. BLOODING is good to prevent an Inflammation and a Fever. The Patient rnuft keep to a moderate Dict. CHAP. XLV. Of the Panaris. B Y the Word TPanaris, I underftand a Colletion or Effufion of fomeMatter, which commonly tak, Operations of SUR GER.R Y 4.e 44 T takes up the Extremity of the Finger, and begins moft times with a fmnall and hard Elevation, without any great Pain and Alteration of Colour; but in time it enflames, grows very red, and occaftons feveral Accidents more or lefs dangerous, according to the Parts in which the Effluflion is contained. IT appears from this Definition, that the Panaris does not always lie in the Extremity of the Finger; that it is not always an apparent Tumor, and that there are feveral kinds of it, as I fhall fhew hereafter. THE Collecion or Effufion of the Liquor, which occafions the 'Panaris, fermenting flowly, produces generally an Abfcefs; and it may be faid that of all Abfceffes none are more painful than the Panaris, by reafon of the particular Strudure of the Skin, and by reafon of the Parts, of which the Fingers are made. BY the Struaure of the Skin at the End of the Fingers, the Learned Mr. 7Duverney obferves, that there are many fmall Sulcus's, partly fpiral, and between thefe Sulcus's, there are two rows of nervous Papillx; whence it is that the Fingers are more fenfible than the other Parts, and by that Mechanifin, Pain muft needs be greater there than any where elfe. As to the Parts, of which the Fingers are made it is well known by Diffedion, that there are in the Infide of each Finger two Arteries, one on each Side, which reaching to the Extremity of the Finger, join and divide into a Million of imall Veffels. Befides, there are two Nerves, one on each Side, which take almoft the fame Courfe. Laftly, if we confider the admirable Difpofition of the Sheath of the Tendons, the Tendons themfelves, which flip in, and the RcrioflJeum, it \4ill plainly appear that the leaft 446 A Treatdfe of the leaft Diforder in thofe Parts muff needs occafion more violent Pains than in all the other Parts of the Body. THUS I have given a general Notion of the Structure of the Fingers; and I think this is a very proper Place to mention the feveral Kinds of Panaris, about which Authors are as little agreed as about the Caufes of that Difeafe, and the Method of curing it. I know four kinds of Panaris. The firft is a fmall Tumor, which happens under the Epidermis, fometimes at the Finger's End, frequently in the external Part, and at the Root of the Nail, and fometimes on the Sides. THAT fmall Tumor begins fometimes in one of the Sides of the Nails, and goes round to the other Side: hence it is that People call it Tourniole, The Vulgar calls alfo that fmall Tumor a Chance-Illnefs, perhaps becaufe they do not know the Caufe of it. THE fecond kind of Panaris is a fmall Tumor, which has a great Affinity with the Phlegmon: It is to be found in the Fat that lies immediately under the Skin, and its Accidents are more dangerous, as the hPhlegmon is nearer the Tendon. THE third Kind of Panaris lies in the Tegument of the Tendon. That Difeafe difcovers it felf generally, like others, by a Tumor; but fometimes there appears no Tumor, as I fhall fhew hereafter. It is more dangerous than the two former, and its Accidents are extremely violent. LASTLY, the fourth kind of 'anaris differs from the others, becaufe there appears neither Tumor nor Inflammation: nay, the Skin which covers the Illnefs does not change its Colour, and the Morbifick Matter lies between the Periofqeum and the Bone. The Pain it occafions is exceffive, Operations of S U R G E R Y. 447 Thofe different Abfceffes proceed from external aknd internal Caufes. The external Caufes of the Panaris, are the Introdution of a Thorn or Splinter of Wood; the plucking off thofe Excrefcences, that grow about the Nails, and are vulgarly called Envies; Contufions or Bruifings, violent Tenfions; lafftly, the Prickings of all forts of pointed Infiruments: Hence it is that Women, who work with the Needle, are more fubje&t to the RPanaris; but then they prevent it by fucking their Finger immediately; wherein they imitate the Suckers of Wounds, or thofe that cure by Suaion, becaufe by that means they draw the Blood that comes out of the fmall Veffiels, and fo prevent the gathering of Matter, and confequently an Abfcefs. IF we enquire into the internal Caufe of the Pa-. naris among the Antients, they will tell us that it is an aduft, bad and corrupt Blood, which Nature expels from the nobler Parts towards the Extrcmities, by ways not eafily conceivable. On the contrary, among the Moderns, fome fay the Tanaris is occafioned by the Corruption and Fermentation of the bilious and fulphurous Particles of the Blood. Others, that it is occafioned by an acrimonious Humour, which corroding the Periol/eum, the Extremities of the nervous Filaments, and the Flefh, produces a fcabby Cruft. Laftly, others will have the Caufe of it to be an extraneous Acid, which mixing with the alimentary Juice, that diffufes it felf between the Fibres, the Membranes, and the frmal Veffels of the Extremities of the Fingers, occafions a Fermenation, which produces the Tumor, the In-. flammation, the Pulfation, &c. Ir 448 A Treatfe of the IT were needlefs to confute the Opinion of the Antients. Many Learned Authors have rejeted thofe unknown ways, which were faid to convey the ill Humours from the noble Parts to the Extremities, and the perfed Knowledge we have of Anatomy, and the Circulation of the Fluids, fhews the Falfity of that fingular Forefight of Nature, which the Antients, through Ignorance, had recourfe to. As for the Opinion of the Moderns, it may be faid, with refpe6 to their firfl Opinion, that the Effervefcence of the bilious and fulphurous Particles of the Blood, is nothing but a Fermentation of thofe fame Particles; and according to that Syftem the Tumor of the Panaris fhould be very painful, from its very beginning, which is contrary to Experience. Befides, the Favourers of that Opinion fay only that the Caute of the Panaris is an Agitation of the bilious and fulphurous Particles of the Blood, without telling us how thofe Particles come.to be divided and agitated rather in the Finger than in the other Parts of the Body; for the Blood being the fame every where, fomething muft needs put into Motion thofe bilious and fulphurous Particles; and that very thing is the firft Original Caufe of the Panaris and the Fermentation of the Blood is only an Effe& of it, as I fhall fhew hereafter. IN Anfwer to the fecond Opinion, it may be faid, that if the Humor, which occafions the Panaris, was from the beginning as corrofive and acrimonious as it is pretended to be, the Pain would immediately be very great; which is not true. Befides, we fhould have been told from whence that Humour proceeds, and what is the Caufe of its Acrimony. Laftly, if an extraneous Acid fhould mix with the alimentary Juice, and occafion an, Effervefcence, attended Operatioml of S uR GER Y. 449 tended with an Inflammation and Pulfation, the Pain could not be finall at firft, fince, according to the mechanical StruLture of the Finger, the Fluid cannot be agitated in thofe Parts which I have defcribed, without occafioning, at that very Moment, a great Diftention, and violent Pains: But we fee no fuch thing at the beginning of the Panaris. As for me, I acknowledge no other internal Caufes of the Panaris, but the Pox, the Scurvy, or the King's Evil; and I never faw any Panaris but what either proceeded from fome external Caufe, or was an Accident of the Difeafcs juft now mentioned. EVERY Body knows that the Lymph of thofe forts of Patients is fo thick, that it flops and accumulates, in feveral Places, grows thicker and thicker, and occafions different Difeafcs. If it be in the Articulations, where there is naturally a clammy Lymph, which we call Sinovia, it occafions there intolerable Pains, Nodus's, gummy Tumors, fometimes A bIceffes, and a thoufand fuch Accidents. If it flops rather in the Tendons, and under the Membrane of the Mufcles, it will comprefs the fmall capillary Veflels creeping in thofe Places, and be the Caufe of an Inflammation, which diftending the Membrane of the Muflle and the Tendon, will occafion thofe Pains which we call rheumatifmal. If it flops in the Glands, it will obftrut and fiell them, and occafion incyfted Tumors, which will be different, according to the different Motion of the Fermentation: Or the Humour will gather into Impoflhumes, and produce Abfceffes, or cancerous Ulcers. Laftly, if it flops in the Finger, whether by rcafon of its particular Struature, or becaufe there is already Sinovia in it, and many Lymphatics, it will comprcfs the G g fmall 450 A 3 reatife of the fmiall Blood-veffels, occaflon a Phlegmon, &c. an Abfccfs, and a Panaris, as I am going to fhew. ALL the external Caufes of the Panaris at likewife by thickening the Blood; for at firfi a Bruife, a Pricking, and all the other Caufes produce a fmall Inflammation, which is not very often minded; and that Inflammation fpreading into many inall Threads, which from the Skin go through the Fat, and even to the Bones, reaching beyond the inclofing Membrane, comprefs the lymphatick Veflels, thicken the Lymph by dillipating its Serofity with their Heat, and occafion the Accidents which I am going to defcribe. THOUGH I have faid above, that all the Parts of the Finger are extremely fenfible, yet the Patient will feel no great Pain at the beginning of the Panaris, becaufi that Lymph gathering only by degrees, the Diftcntion and Divulfion of the Fibres will be made alfo by degrees, and confequcntly the Reflux of the Spirits will not be violent, or the Pain extraordinary. BUT becaufe the Stru&ure of the Finger is very fingular, and it confifts altogether of Parts very fufccptible of Agitation; 'tis plain that Tranquillity will not laft long, and will be attended with very fad Symptoms. For becaufe that Lymph accumulates to fuch a degree, that it compreffcs the Veins very much, and becaufe thofe Veffcls cannot receive the Blood as it is conveyed by the Arteries, the Blood of the Arteries will not move in a ftraight Line, but get into a Million of fiall Branches that come from the two Arteries of the Finger, as I have faid, to reach the Skin, and confcquently it will grow red more and,more. r.TLY, the fmall Branches not being able to recciVC Operations of SUR GE R Y. 4 t ceive all the Blood of the two Arteries, and give it a free Paffage, that Blood accumulating will difftend them to fuch a degree, that it will break fome, and extravafate whch cannot happen, without giving a lively red Colour to the Part. BUT becaufe thofe Accidents are more obvious in the two firft Kinds of Panaris, fince the Difeafe is only covered with the Skin, or one of its Parts; and bccaufe that Membrane yields much more than the Membrane of the Tendons, and the RPeriafleum, which lie underneath, it follows that in the two firft Kinds of Panaris, the Tumor will be confiderable, but in the fecond Kind it will lie deeper in the Articulations, becaufe there is hardly any Fat, and becaufe the Skin is there fupported by Ligaments which proceed from the Bones; and therefore the Pain of the fecond Kind of 'Panaris will be fliarper than that of the firft, efpecially confidering, that int this fort of Panaris, the Texture of the Skin is not diftended. And becaufe the Fever is a Confequence of the Pain, 'tis plain the firit Kind of Panaris will not be attended with it; but there will be fome Fec ver in the fecond. THE Pain, that is felt in the Part, draws untd it a greater Quantity of Spirits, and therefore thofe Spirits, mixing with the Blood that is fltopped, will agitate and ferment it very much. That great Heat, and extraordinary Fermentation, will agitate and ferment the thick Lymph to be found in the Part: Therefore, the Blood and the Lymph will fuppurate and produce an Abfcefs, as it generally happens in the 'Panaris. Bur if all thofe feveral Alterations are made in the Membrane of the Tendon, the Pain will be very Violent, and attended with a ftrong Pulfation, beG ga caufe 451 A 'Teatife of the cailfe the Courfe of the Blood being almoft whoifr interruptcd in that Part, every time the Heart conveys new Blood, it muft needs keep afunder the Coats of the Arteries, fince it cannot go forwards by reafon of the Compreflion, and confcquently it muft increafe the Pain by incrcafing the Diftention. That Increafe of Pain muff therefore anfwer the Contra[ions of the Heart, and this is what we call a pulfative Pain. BuT becaufe the Membrane of the Flexors is almoft cartilaginous, and does not yield to the great Fcrmentation of the diffufed Matters, the Tendons of the Sziblimis and 'rofundus will bear alone the Adion of the grofs Salts of the diffiufcd Matters, and be very much irritated by them. And becaufe thofe Parts are very much diflended by reafon of their continual Contradion; it is plain they can receive a great Motion, impart it to the Spirits contained in them, and occafiton a violent Reflux towards the Brain, which will immediately be attended with the Return of the Spirits towards the Part; and confequently they will excite very great Pains, which generally occafion Infomnies, violent Fevers, Convulfionis and 'Deliriums. LF the Heat and Inflammation are as great as I fuppofe them to be, they muft needs wafte all the ferous Parts of the Lymph, which has occarftoned that Difeafe, that which has been accumulated fince, and the Sinovia, which is contained all along the Infide of the Sheath. Thofe Fluids having loft their ferous Parts, will be thicker, and being, as it were, concoacd by a violent Heat, they will be hard and clotted, as appears by opening that fort of Panaris. LASTLY, Operations of S u RG E R Y. 4 LASTLY, the Pains increaflng continually by reafon of the Irritations, which grow by Degrees exceflive, 'tis plain the Return of the Spirits towards the Part will increafe, be more frequent, and get into the adjacent Parts with great Violence. The adjacent Parts of the Finger being moft of them Tendons, Membranes, Aponeurofes, and nervous Threads, their Fibres will be full of them, and will occaflon a ftrong Compreffion upon the lymphatick and Blood-veffcls, which creep in the Interflices. Thofe Liquids will diffufe themfelves, ferment, and occafion a very great Inflammation in the Hand, in the foreArm, and in the Arm, even as far as the Shoulder: And the Inflammation diffolving the Fat, to be found in Bundles, in feveral Parts of the Extremity, will produce thofe Abfceffes, called Abfccftes with Sinus's. Therefore, in the third Tort of Panaris there will be afterwards an Abfcefs, not only all along the Sheath of the Tendon, but alfo under the annulary Ligament, between the Quadratus and the 'Profundus, where a Bundle of Fat is fecn, in the Interflice of many Mufclcs of the fore-Arm, in the Fold of the Elbow, laffly, as far as the Arm-pit, ALL the Accidents juft now mentioned will happen in the fourth fort of Panaris, excepting the Abfcefles with Sinus's, and the Inflammation of the adjacent Parts of thp Difeafe; and they will be the more violent, becaufc the Lymph, which is the Caufe of the Difeafe, is diffufed between the Bone and the Periofleum, which is a Membrane very much diftcnded upon its Surface, and confequently fufceptible of a trembling Motion; and as it is intimately faftened to the Bones, by an infinite Number of finall nervous and tendinous Threads, if it happens to be never fo little inflamed, that Inflammation muft SG g i needs .454 A.Treatife of the peeds create fuch violent Pains, that the faddeft Symptoms, arifing from Pain, will follow thereupon. HAVING examined the different Caufes of the Panaris, both internal and external, let us proceed to the Signs which denote the different Kinds of that Difeafe. A Surgeon knows the firft Kind of Panaris, when the Tumor is very much raifed, when the Matter, that occafions the Difeafe, may be feen, becaufe the Epidermis that covers it, is a tranfparent Membrane, when the Pain is not intolerable, and does not reach beyond the Finger, when there is no Fever, and the other Signs above mentioned do not appear. THE fecond Kind is attended with the fame Symptoms; but they are more violent, and there happens a little Fever, the Heat and Inflammation are confiderable; and there is a Numnefs in the whole Hand, with Pains and Prickings all along the internal Part, which fometimes reach as far as the fore-Arm; and thofe Pains are often attended with want of Sleep, efpecially when the Patient is of a flender Compleftion. ONE may know the third fort of the Panaris by a fmall Tumor, which frequently appears at the Finger's End. Sometimes there is no Tumor, as when the morbific Matter lies in Articulations, becaufe the inclofing Membrane is there faftined by fmall Bridles, which hinder it from yiclding. But the Pains are intolerable, and the Patient feels them in all his Fingers, if the Difeafe happens to be in one of the four flexors. The fame Pains are felt all along the Hand, in the Wrift, towards the anniulary Ligament, wherq they are very violent, and all along the foreArm, as far as the internal Condylus of the Humerus, yhich is the Origin of th, Smbfiirs and Trofun Operations of S u R G E R Y. 4T5 dus. Sometimes thofe Pains reach no farther; but the Inflammation of thofe Mufcles being communicated to the proper Membranes of the brachial and anterior Mufcles, the Biceps, and the Flexors of the fore-Arm; the Pains reach to the Arm, the Armpit, and the Shoulder. THOSE Pains always occafion a burning Fever, and commonly want of Sleep, Convulfions, and 'Deliriums. If the Matter caufes Abfccfes with Sinus's, the Tumor is not confiderable all along the Finger, becaufe the inclofing Membrane is very hard, and does not expand much; however, one may perceive finall Tumors in the Interval of the Articulations. The Tumor is very confiderable in the Hand; but the Pains are not fo fharp. Laftly, the whole Hand, the Fore-arm, and the Arm fwell very much; and in fome of thofe Difeafes, I have feen the Arm as big as the Thigh. THE fourth Kind of ~Panaris may be known by a moft violent Pain at the Finger's End, in the laft Phalanx, and fometimes in the others, and by a very great Fever, want of Sleep, and frequent 'Deliriums and Convulfions. That fourth Kind of Panaris is further known, becaufe notwithftanding all thofe Accidents, there appears no Tumor 'nor Inflammation, and the Patient feels no Pain in the internal Condylus of the Humerus. THE Prognoftick of the Panaris is more or lefs dangerous, according to its different Kinds, The firft Kind is not at all dangerous; only if that Difeafe furrounds the Nail, it generally falls; and if it furrounds but one Part of the Nail, that Part only will fall, for the mechanical Reafons of the Formation and Growth of the Nail. And if G g 4 the 4 6 A Treatfe of the the Matter is contained under the Nail, that Kind of Panaris, though very fimple, occafions very great and dangerous Pains, becaue the Nail cannot yield to the continual Afflux of Matter, and its Fermentation. This is the beft Account that can be given, why a Pricking under hard Bodies, fuch as the Nails, under the Hoofs of Horfes, under the Afoneurofes, under the Sheaths of Tendons, d~c. is more dangerous than any other. THE fecond Kind of Tanaris proves generally more dangerous than the firft, becaufc it is contained under the Skin, whofe Contexture is very clofe, and confequently making a greater Refiftance, it occaftons more violent Pains, attended with a confiderable Fever, in People of a weak Conflitution. THAT Difeafe, as well as the two following Kinds, is ftill more dangerous in People of a dry and bilious Conftitution, becaufe their Fibres being drier, are more diftended, and confequently more able to receive a firong Impreffion, and to be more violently fhaken. The Prognoftick of the third Kind of Tanaris is much more dangerous than that of the two firft, becaufe the Pains are much iharper, and the Fever fo violent, that all the Accidents of that Difeafe appear in their Height, and frequently occafion the Death of the Patient. Befides, that Kind of Panaris is extremely dangerous, becaufe it is often attended with the Gangreen, efpccially when the Blood is faline and vitiated; for the Pains of the Tendons being very fharp, and the Spirits flowing into them in great plenty, if the Blood that is flopped in them be faline, it produces an Eryfipelas; and its corrofive Salts being very much agitated, by the great Quantity of Spirits mixed with them, corrode and tear all the Fibres Operations of SUR GER Y. 457 Fibres of the Part, and fo occafion a Gangreen. ALL the different AbfcefTls, which attend that Difeafe, as I have faid above, muft needs afford a very dangerous Prognoftick. When a Surgeon is fent for to fee a 'Panaris of the third Kind, wherein he finds an Abfcefs with Sinus's, and an Abfcefs upon the Quadratus; he muft tell the Patient, in the Prefence of Witneffes, that the Operation is the only Way of curing him, but that he will lote the Ufe of his Finger, left he fhould be blamed for it. LASTLY, the Prognoftick of the firft Kind is not lefs dangerous than the foregoing, fince the Pains are fo exceffive, and the Accidents fo violent, that the Patient would quickly die, if he was not fpeedily relieved. Betides, the Bones are frequently rotten in that Difeafe; and if it be the laft Phalanx, as it is very thin, it generally falls off during the Dreflings, &c. CHAP. XLVI. Of the Operation and Cure of all Kinds of Panaris. T H E firft Kind of Panaris to be cured is very inconfidcrable, and requires no great Attention. Surgeons are very fubjeat to it, becaufe they are frequently obliged to fallen Pins upon wet Compreffes and Fillets, grown fliff with the Fluids they are often imbibed with, and the Pins making a great Refiftance to the Finger that drives them in, their Head bruifes the fmall Veiffls on which it leans; and there happens quickly a fmall Phlogofis, which occafions that Kind of 'Panaris. As foon as the Surgeon 45y8 A Treat 4 of the Surgeon perceives fome Matter, or Scrofity, he muf comprefs the Tumour gently on the Sides, thereby to brace the Epidermis; and with a Launcct he mnakes a fmall Incifton in that Membrane. The Liquid comes out immediately; and the Skin, which nmuft not be removed, quickly dries up, and confequently the Difeafe is eafirly cured. IF the Panaris was in the external Part of the Finger, at the Root of the Nail, the latter will fall off, either wholly or in part, and as the Nail grows loofe, and comes off, it grows black; and becaufe the new one pufhes it ftill forwards, either Whole, or the Part that remains of it, it muff be pared now and then. IT happens fometimes, either by a pricking, or otherwife, that the Matter is contained under the Nail; and though the Panaris be of the firft Kind, it would prove very dangerous, if it was not remedied; for the Pus would corrode as far as the Extenfor of the Finger, and occafton great Inflammation, and Pains that would be communicated to the external Condylus of the Humerus, from whence the Extenfors of the Fingers take their Origin. To avoid thefe Diforders, the Surgeon muff cut that Part of the Nail, which covers the Matter that corrodes it with difficulty, and having taken it off, he puts in the room of it fome Lint dipt in Brandy, Jeft the Uncqualitics of the Nail fhould hurt the live Flefh, which is very fenfible. THE fecond Kind of 'Panaris being generally attended with a fmall Fever, and becaufe People of a weak, or dry and bilious Conftitution, run a great Hazard, the Surgeon muft blood the Patient plentifully, and prefcribe fofteiing Remedies, and all thofe that can allay the great Agitation of the Blood. TiE Operations of SUR GER Y. 49 THE Surgeon generally feels, in a little time, a fall Fluftuation; and the beft Remedy would then be to open the Tumor, in order to let out the Matter, and prevent its further Accumulation, becaufe thofe Phlegmons make always a great Havock, as they come near the Sheaths of the Tendons. But as foon as a Surgeon propofes that Operation to the Patients, they fend for Quacks, being prepoffeffed in favour of their Remedies. Thofe Men, without Learning and Principles, apply a Plaifter, of which they pretend to have invented the Compofition, and make a great Myftery of it: And becaufe the Tumor does frequently break in twelve Hours, that myfterious Plaifter, which they ufe for all forts of Difeafes, feems to triumph over Surgery. WHEN therefore the Patients are againft the Operation, which is the fafelt and molt fpeedy way, the Surgeon mutl ufe Remedies proper to encreafe the Suppuration, and open the Abfcefs, This will be effedted by the Plaifler of 'Diachilum with Gums, or fuch other Remedies. AssooN as the Tumor is opened, he inlarges the Opening with Sciffars, and dreffes it with fome melted Balm of Arcxeus, into which he puts a little Brandy, and lays over it a Plaiffter of 'Diachitlur, &c. WHEN the Surgeon has obferved all, or fome of the Accidents, which attend the third Kind of TPa naris, he perceives fomctimes a fmall Tumor at the Finger's End, wherein he feels a Fluftuation. He muft then make an Incifion all along that Tumor, with a firait Biflouri, as far as the Sheaths of the Sublimis and Profundus. Through that Opening there comes out a fcrous Matter 5 and by that Evacuation the Patient is immediately cafed. He fancics 46o A Treatfe of the cies he is cured; but foon after, the fame Accieknts appear again, the Patient is in great Pain, and the Surgeon is frequently ignorant of the Caufes of thofe fad Symptoms. Sometimes the Matter having corroded the Extremity of the Sheath of the Tendons, and the Texture of the Skin, it opens a Paf. faghe, whereby the Patient is eafed for a Moment; but foon after, the Accidents begin anew; and the Surgeon perceives in that Part, where the Matter sme out, a fmall Piece of Flefh, like a Caruncula, which is extremely fenfible, and continually imbibed with a Moiffure, that comes from a fuperior Part. THE Surgeon muft then introduce a grooved Probe into the Sheath of the Tendon, either through the Opening which he has made, or through the Opening occafioned by the Serofity it felf, and drive it beyond the firft Bridle. Afterwards, he muff cut wvith Sciffars, or with ' Btýouri, what is contained under the Probe, and he will find, at the Opening, a clotted and thick Matter. SBUT if the Difeafe reaches farther, he muft ffill drive the grooved Probe all along the Sinus of the Abfcefs, and cut what will be uppermoft, till he has difcovered the Seat of the DifRafe. IF the Seat of the Abfcefs be in the Middle of the Sheath, and the Surgeon has dilated the Opening as far as the Middle of the firft Phalanx; Mr. Petit advifes one to carry on the Incifion three or four Lines into the Hand, to avoid the Conflrition occafioned by the remaining Part of the Sheath, vhich is cartilaginous all along the Finger, and which being onlymembranous iii the Hand, cannot be the Caufe of that Accident. LASTLY, if the Difeafe lies all along the membrae nous Sheath of the Tendons of the Hand, and even reaches Operations of SURGERY. 46i teaches under the annulary Ligament, to form an Abfcefs upon the gQuadratus, where, as I have faid, there is generally a Bundle of Fat, the Surgeon muft always convey the grooved Probe all along the Sinus of the Abfcefs, and cut, till he comes to the annulary Ligament. There he bends a little the Fingers of the Patient, to relax all thofe Parts, and endeavours to drive the Probe under the annulary Ligament; and upon its Extremity, which raifes the Skin, he makes an Incifion only in the Skin; he divides the Tendons and Mufcles, as nicely as he can, and falls all of a fudden into an Abfcefs, out of which there comes fometimes above half a Surgeon's Porringer of Matter. WHEN the Surgeon is fo lucky as to be able to convey the Probe under the annulary Ligament, Mr. Thibaut advifes one to convey alfo under it a FilIct or Rowel,which being inftead of a Seton,will take off, in the following Dreflings, the Lymph, which is grown corrofive by the Separation of its Principles and by that means he will avoid cutting the annulary Ligament, which ought to be preferved as much as poilible. IF this Precaution proves ufclefs, and the Patient is ftill tormented with great Pains, a Fever, and other dangerous Symptoms, Mr. Petit propofes an Expedient, which immediately removes the Accidents, and is a fpeedy Remedy. He advifes then to draw the Tendon affc&ed with the Difeafe above the annulary Ligament, and to cut it in its flefhy Part: which being done, all the Accidents vanifh. LASTLY, if the annulary Ligament it felf is imbibed with Pus, that is the Cauwe of the Difeafe; if it be inflamed, and occafions violent Pains, it ought to be cut without any Hefitation; and the SPatient 46z A r'eatife of the Patient will quickly bc cafed. This has been pradticed feveral Times by Mr. Arnaud. I faw, in September 1713. a Servant of Mr. Gillet, Dean of the Attorneys of Paris, affected with a very dangerous Difeafe. A Thorn got into his little Finger. Not long after, there happened a confiderable Inflammation, attended with great Pains. The Surgeon applied a Poultice, and blooded the Patient plentifully; and then there appeared a fmall Tumor, upon which Mr. Poncelet made an Incifion three Inches long. One half of that Incifion took up the fore and upper Part of the Finger, and the reft took up the external and lower Part of the Hand. The Patient was not cured by that Incifion. He felt every Day new Pains, efpecially towards the internal Condylus of the Humerus, which is the Origin of the 'Profundus, whofe Tendon had bee pricked by the Thorn; and a great Abfcefs was formed in the whole fore-Arm, which was perceived by a fmall longitudinal Tumor in its lower and hinder Part. Mr. 'Poncelet made an Incifion upon the Tumor and putting his Finger into the Opening, enlarged it with crooked Sciffars. A great deal of thick Pus came out, and it proceeded in fome meafure from the upper Part of the fore-Arm. Afterwards, putting his Finger into the Wound, he funk it into a Vacuity reaching to the Middle and fore-part of the fore-Arm, where he made a counter-Opening, into which he conveyed a Rowel, fo that this Seton was between the Cubitalis Internus, the Sublimis and 'Profundus, the Radialis Internus, and the two Bones. MR. 'Poncelet dreffed that Patient evety Day with the digeflive Ointment, and the neceffary Embrocations, changing the &eton every time; and ten Days after, Operations of S0 u R E R,. 4K3 after, when the Ulcer did no longer fuppuriate, he took off the Seton. But the very next Day there happened fo great anErjfpelas in the whole Arm, that it would have occaftoncd the Gangreen, if the Patient had not been fpcedily relieved by frequent Plebotomy, and the Rowel which was put in again for two or three Days. At lahf, he was perfcaty cured in fix Weeks time. To refume our Operation, if after having opened the Vagina of the Tendons, as far as the annulary Ligament, there is fo great an Impediment, that the Surgeon cannot convey the grooved Probe underneath, to get into the Abfcefs, which I fuppofe -to be upon the jQuad-ratus, he muff ufe a particular Method, as will appear by the following Story. Mr. Arnaud was fent for to confult with feveral Surgeons about a Ranaris, which a Man had in his Thumb. The Surgeons had already opened the Tumor, and cut the Thenar almoft alL along. They told Mr. Arnaud, that clotted Matter was come out, like that which comes out of Boyls; and becaufe the Accidcnts, infead of ceafing, had very much increaW fed, and the fore-Arm was very big and inflamed, they fancied there was no other Remedy but to cut off the Arm. Mr. A4rnaud rcfledting upon the StruCture of the Part, told them, that the Flcxor of the Thumb has a peculiar Tendon, which attends its flefhy Body as farf as its Origin; and that between the Ilefhy Body and the guadratus there is a Bundle of Eat 3 fo that the Inflammation being in the Tendon of the Flexor of the Thumnb, and reaching as far as its Origin, it had, by its Heat, put into great Motion the Blood, which circulates in the Bundle of Fat, and diflipatcd the Scrofity of the Lymph of that Fat, 464 A Treattfe of tbe Fat, and the adjacent Parts. That thofe Fluids ha2 ving loft their Serofity, it was plain their Salts were grown coarfer, and confequently more capable of irritating thofe tendinous Parts; which had ftill increafed their Inflammation, and the great Heat, which having melted that Piece of Fat, had occafidned an Abfcefs. So that in order to free the Patient from the Danger he was in, there was an abfolute Neceflity for cutting between the radial Artery, and the Sublimis and 'irofundus, and to look for the Abfcefs under the Flexor of the Thumb. THE Surgeons, who had fent for Mr. Arnaud, refufed to confent to an Operation unknown to them; and becaufe upon fuch Occafions the Majority of Votes carries it, they left the Patient till the next Day. But perceiving the Difeafe to increafe more and more, and having no Hopes of the Patient's Recovery, they fent again for Mr. Arnaud, who faid, There was no other Way left but that he had propofed. The Surgeons confented to it at laft; but becaufe none of them would undertake the Operation, Mr. Arnaud performed it by difl'efing, as I have faid, and immediately fell into an Abcefs, out of which came above a Porringer of Matter; and becaufe the annulary Ligament made a confiderable Conftrifion in all the Tendons that pafs underneath, he did not fcruple to cut it; and the Patient was prefently eafed; and the very next Day all the Accidents, which threatned him with Death, difappeared wholly. The Patient perfetly recovered by a careful Attendance, and with the Help of fweetning Juleps, Clyfters, and a very regular Courfe of Diet. Mr. Petit obferves that the Hand muff not be firetched out, when the annulary Ligament has been cut; Operatiois of S u R G 1 R P. 465 46y cut for in that Situation, all the Tendons come out of their places, and the Paticnt remains lame, On the contrary, the Hand mufl be fhut, that the' Ligament may be more eafily rcunitcdd IN ordcr to drefs the Panaris, when the VargIna has been opened, the Surgeon ufes long and dry Do. zels, which he applies on both Sides of the,Tcndon1 to pxefervc it j and he fufficiently raifes them to make a Compreflion, that may prevent an Hemiorrhagv; and if this Way is not jitfficient, he ufcs the Ligature; for upon this Occafion Stipticks are dangerous. THE Surgoon lays upon the Hand and the forcArm, maturative Poultices as warm as lie c,,1n. He ufes a Bandagc with cightcen Heads, \X hich is much more convenient than Rollers, becaufe it anfwers the faime Purpofes; and befidces, in order to apply it, there is no need of ftirring the Part, or giving it any Motion. Of the Bandage with eighteen Reads, To make that Bandage, the Surgeon ufes three Pieces of Linncn of the fame Size, and of a figure almoft fquare. In general, the Bandage with eahteen Heads ought to be fomewhat fhortcr than thod Part upon which it is applied, and twice as broad as it is thick. The Surgeon fows thofe three Pieces of Linnen together, in the Middle, length-witfe. Afterwards he cuts the three Pieces fowed together1 in two different Places on each Side of thr Seam, taking care to leave all along the middle of thofe Pieces two whole Inches, I mean an Inch on each Side of the Seam. Thofe Cuttings, viz, two on cach Side, and of an equal Diflance, form cigh-l H 1i 466 A reat~'fe of the tccn fmall Shreds, which is the Reafon it has been called a Bandage with eighteen Heads. It is rcckon'd among the compounded Ones. THE Surgeon applies the Seam of that Bandage upon that Part of the Member, which is oppofite to the Wounds that have been made, and covers the Drefling with the fimall Heads, beginning with that which he thinks fitteft. But it ought to be obfcrved, that whilft one of thofe Heads is convcyed with one Hand, the oppofite Head mufft be held at the fame time with the other Hand. Afterwards the Hand and the fore-Arm muff be placed in a proper Situation. IWHAT remains, to make an End of the Cure of the feveral Sorts of 'Panaris, is only to difcourfe of the fourth Kind, the Pains whereof are fo fharp and violent, that the Patient runs the risk of lofing his Life, unlcfs he is fpeedily relieved, by evacuating the Matter, which is the Caufe of the Difeafe. FOR the right performing of that Operation, the Patient's Finger is laid upon a Table; and fome Servants hold his Arm, left the Pain of the Incifion fhould prompt him to pullit back. AFTERWARDS the Surgeon takes a Biflouri, whole Blade is faflened with a Fillet, and he opens the lateral Part of the Finger, beginning with driving the Point of the Inftrument to the Bone, and laying open the remaining Part of the Finger by fliding the B;ftouri. IF the Patient is not eafed by that Opening, it is a Sign the Difeafe lies on the other Side of the Finger, where the fame Operation ought to be performed. Sometimes a clear Water comes out in fmall Quantity, and frequently nothing at all; but when the Accidents difappear immediately, 'tis a plain Proof of the good Succefs of the Operation. THE Operations of SUR GER Y. 467 THE Drefling is very fimple but becauife that Difeafe happens more frequently to People affetecd with the King's-Evil than to others, it is not improper to enquire about it, and to give fuch Remedies as are adapted to the Conftitution of the Blood in the different Difeafes, that may occafion this. C H A P. XLVII. Of the Gangrene and Sphacelus in relation to Amputations. T'HE Gangrene being one of the chief Reafons, that induce us to cut off a Limb, it is not improper to inquire into the Caufes of that Difeafe, and to'know the different Degrees, that we may pre. fcribe the fevcral Remedies proper for it, according to its Differences, and the Progrefs it makes in thofe Parts that are affected with it. THE Gangrene in general is a Mortification of the foft Parts of the Body; and confequently a -Lofs of Senfe, Motion, Heat, &c. IF thofe Accidents are juft beginning, I mean, if the Mortification is only in the Skin and Fat, and there remains frill fome Senfe and Heat in the Part, it is then a Gangrene. But if that Difeafe has made a greater Progrels; if the Body of the Mufcle is almoft rotten; if there is neither Senfe, nor Heat, if the Part looks very black, and is grown foft; if the Epidermis comes off, and a kind of Slime is to be fcen in it: Laftly, if there is an ill Smell, we call it a Sphacelus, or a perfect Mortification of the Part. H hh IF 468 A Treat/fe of the IF the Parts of the humane Body grow fenfble, are nourished, and receive Heat only by the Spirits running into them, and by the Blood with which they are imbibed; it is plain the Corruption or Defec6 of thofe Fluids will make the Parts inienfible, prevent their Nourifhment, and deprive them of their natural Heat. ACCORDING to this Notion, the Caufes of a Gangrene arc of two forts. Some of them concern the DefeIs in the Fluids, which circulate in all the Parts, and others depend upon the Diforder of the Solids, which may happen feveral ways. IN order to explain how the vitiated Fluids, that circulate in all the Parts of the Body, can produce a Gangrene, we muff confider the good Effecs arifing from them, when they are in their natural State. SINCE the different Parts of the Body are capable of feeling, only by reafon of the Spirits, which come from the Brain, and running back again towards the Brain, give it notice, as it were, of all the Impreflions that are made upon the Parts from whence they return; it follows, that when the Spirits are wanting in fome Part, either becaufe its Nerves are ftopped by any Caufe whatfoever, or becaufe they are compreffed by fome adjacent Tumors, or becaufe the Blood is difpofed to produce Obftruftions, the Part will grow infenfible. This happens to People fick of the Palfy, &c. BUT becaufe Infenfibility is only a Difpofition to a Gangrene, and there is in that Difeafe a want of Heat, Nouriflment, and Motion, it is plain that the Blood, which alone can afford Heat, &c. is no longer conveyed to the Part, or able to communicate any Heat to it. A Gangrene frequently happens that way, I OperatIons of SUR GER Y. 469 I mean, by the Interruption of the Blood, as I fhall fhew hereafter. But it likewifc happens from the Corruption alone of that Fluid. IN order to apprehend how the Corruption of the Blood in a Part can make it cold, and deprive it of its Motion, one muft know how the Blood can heat the whole Body. Now the Blood communicates, to the feveral Parts, the Heat it derivcs from the Fermenntation of the Principles of which it confifts, and from the Motion of Pulftion, which the heart imparts to it, and which prefcrvcs the Fermentation. Therefore, if the Principles of the Blood be vitiated by any Caufe whatfoever, and if they are no longer animated by the Spirits, that Fluid will lofe, either wholly, or in part, its Motion of Fermentation and confequently its Heat. THE Heart being the firlt Part, that experiences the fad Effed1s of the Diforder of the Principles of the Blood, its Piflon-like Strokes will be weak, and at a great diflance from one another; and. confequently the Motion of Trulion growing very flow and keeping up no longer the Motion of Fermentation, the Particles of the Blood will be very little agitated: They will flick and be united together, in fuch a manner, as to form a Coaguff!wum.0 THE Caufcs, which can thus alter the Blood, and qualify it for a Gangrene, are A. Repletion, fitting up late, violent Exercife, and the uCe of hot Aliments and Liquors. z. Some Pafflons of the Mind, fuch as Sorrow and Trouble, hard Study, great Hemorrhagies, and the ufe of cold Aliments. LaJ/Iy, Old People afford us the third Canife. To explain thofe 'henom;na, I fhall obferve, that fitting up late, &oc. having occa o.ed a great Agitation of.the Blood, and a violent Fermientation of its H h 3 Princi 470 A Treatife of the Principles, it neceffarily follows, that its moff fubtle and watery Particles are evaporated, and that the remaining Salts becoming, by that Separation, very grofs, and being very much intangled in the fulphurous Particles, have qualified the Blood for a Gangrene. SECONDLY, Trouble, Sorrow, and hard Study, great Hcmorrhagics, &cTr giving a Confiflence to the Blood, and fermenting it irregularly, and in a very particular manner, its Salts will change their Nature, according to their different Combinations, and will grow fo corrofive, that they will be able to produce different Difeafes, cfpecially a Gangrene. THIRDLY, Old Pcople are very much fubjcL to Gangrenes, becaule their Blood having undergone a long Fermentation, and repaired all the Diffipations, during the whole Courfe of their Life, it is at laft deprived of thofe ifuibtle and ipirituous Particles, which produced the Motion of Fermentation; and its Salts become fo much the groffer, as the Heart beating but weakly, occafions a clofer Union of them. And therefore old People lofe their Strength, and their natural Fundtions by degrees, becaufc the Tibres of their Organs having acquired their laft Degree of Extenfion, and loft infenfibly their natural Supplenefs, they lofe, at the fame time, their Elafticity, and a Gangrene happens. A Gangrene, occafioned by the Defea1s of the Blood, does generally affe&t the Extremities; but it quickly reaches the whole Body, notwithflanding all the Remedies that can be ufed. If it appears in the Extremities fooner than in other Parts, it is becaute the progrcflive Motion, which the Heart communicates to the Blood, being very weak in fiuch a difordered Conflitution, becomes fiil more fo before it 1OperaitiONS f S U R G F R Y. 4of it comes to the Extremitics. This happcns the more cafily, becaufe the feveral Parts it goes through, have loft almoff their whole Elafficity, and are very flabby for want of Spirits; fo that thofe Parts receiving a great deal of Motion from the Blood, and inipart. ing none to it by rcafon of their Softneci'; it follows, that the farther the Blood is from the Ccnter of its Motion of PulCuion, the lcfs it will be agitated. BUT if thc Motion of Fermentation, to be found among the Principes of the Blood, is kept up by the Motion of Pulfation; it neceLarily follows that the latter being very mnuch lckned, as I have fhmwed, by an undeniable Mcchanif-h, is no longer able to keep up the Motion of Fesgcrtation; and confequently the Blood will have no MIotion in the Extremities, or very little: So that the Principles of that Blood bcing~- no longcr agitated all manner of ways, nor mixt, its Salts will be at liberty to ftrike together, and to form co.rofive Aiolecu/x, which will tear and deiroy the Texture of the Part, and fo produlce a Gangrene. BESIDES the Defecis of the Fluids, which circulate in all the Parts of the Body, 1 have faid, that a Gangrene is frequently a Confequence of the Diforder of the Solids. THAT Diforder happens fcvcral Ways. For Infiance, the large Trunk of a Vcfcl may be cut with Iharp Infiruments, fuch as Scifhrs, Swords, Sabres, Axes, &c. THE large Veff'els may alfo be torn by Bails going through the Limbs, or by Splinters of iBones in a FraCture. AN Ulcer lyring near a large Veffiel, when its Pus is firous and corrolive, may corrode it by degrees, open it, &c. H 11 Tm;~H 47 z1 A Treat-/e of the THE Diforder of the Solids is alfo occafloned by different Compreflions; for the large Trunks of the Blood-veffels or Nerves, may be compreflfcd in a Luxation by the Head ot the Bone, that comes out of its Cavity, and makes a confiderable Protuberance. All forts of Veffles may alfo be compreffed by adjacent Tumors, fuch as dilended Glands, and Scirrhus's. The Liratures of the Veffels are alfo fometimes attended with a Gangrene, as appears in the Operation of the Aneurili. The fame may be faid of [3andages too tight, as it happens fometimes in Fractures, cfpecially when the Splinth has been ufed. BEsIDEs all thofe Caufes, the Tendons of the vlufcls may ailfo be conftrited by their annulary Liganments, in conicquence of fome of their Ditcates; and they may occafion fo great a Diforder, that a Gangrene will enfue, as I have flhewed at large, difcourfing of the 'Panaris. The Mufcles are liable to the fanmc Accident in their flefhy Part, by the Inflammation of their own Membranes, or of the common Aponeiuroffs with which they are covered. And therefore Surgeons advife to make an Incifion, which not only cuts the Skin, the Fat, and the 4Aoncurofis, but alfb opens the Membrane of the Mufcle to f'ct it at liberty. LASTLY, the fatty Cells, being too much imbibed with Scrofity, may be extraordinarily dilflended; which occafions a Lihature in thofe Places where the Skin is folded, as in the Fold of the Arm-pit, &rc. This happens in a great Oedtma, and in Dropfics. All thlofc Accidents preventing the Blood from running into the Parts in a proportionable Quantity, or keeping the Blood and the Lymph in Ibfome Places, produce there different Gatherings of Matter, w\hich -are frequently attended with a Gangrcne, though there be no DefeCt in the other Fluids. THE Operations of SUR G E R Y. 47 3 THE diagnoftic Signs ofa Gangrene are fufficiently known by what I have faid of it: However, becaufe there are certain Signs, which denote its Caufes or Degrees, I fhall mention fome of them. A Gangrene, occafioned by the Defects of the Fluids is known, becaufe it is not commonly preceded by an Inflammation, or great Pains: the Parts grow flabby, and the Limb lofes all Scnfc and Motion. The Patient has a lingring Pulke, and is fubjea to frequent Weakn eflcs. A Gangrene, which attends the Diforder of the Solids, proceeding from many Caufes, is alfo different; for that which is occafioned by the Opening of the large Trunks, begins without a gathering of Blood about the Veffels, or with fuch a gathering. If it arifes from the firft Caufe, there being no Inflammation, the Accidents are much the lame with thofe that follow a Gangrene occafioned by the Defects of the Liquids. But if there is a confiderable Effufion, attended with an Inflammation, the Pains are violent (as 1 have faid, fipeaking of the 'Paznaris) the Colour of the Limb is very red, and the Heat extraordinary; fo that a Gangrene wvill fuicceed all thofe Accidents, when the Pains are over; the Limb will be pale and purple, there will be fome finall Rifing in the Skin, full of lalt Water the Part grows cold and flabby the Impreflion of the Finger remains in it; and it lofes all Senfe and Motion. This may further happen (as I have faid) in the Inflammation of the annulary Ligaments, of the Tendons, and the flethy Part of the VMufcles. IF a Gangrene fucceeds the Interruption of the Spirits, as it happens upon the Compreflon of the Nerves and Blood-veiels, occafioned by fome Luxations, by glandulous or fcirrhous Tumors, by the immediate 4741 A7A Teat;fe of the immediate Ligature of the Veflils, or by over tight Bandages; it is known by.a Numnefs, which the Patient feels all along the remaining Part of the Extremity, and which is quickly attended with the Lofs of Senfe and Motion. IF a Gangrene I`uhecceds a great Oedema, or a Dropfy, becaufe the fatty Cells being too' much imbibed with Scrofity, occafton Ligatures where the Skin does generally make Foldings, as in the Fold of the Arm-pit, &c. The Patient does not immediately feel a great Pain but the Inflammation happens afterwards, and the Pains grow more violent. LASTLY, the Sphacelus is known by a heavy Pain, and a confiderablek T Weight in the Limb. Befides, there is a Diflention in the adjacent Parts. For Infiance, if it be the Leg, the Thigh will be diftended; and if it be the Thigh, the Buttocks, the Loins, and frequently the Back will be diffended and oedematous. If it be the Arm, the Diftention will be in the Shoulder, rc. THE Prognotfic of a Gangrcne in general is very dangerous, for fince it is a Mortification of the afflidted Part, it is the moft deplorable Condition it can be in. A Gangrene is extremely dangerous, not only-by reafon of the Corruption of the Part, but alfo becaufe it reaches the adjacent Parts, by communicating to them Salts, which coagulate and diforder the Blood about the gangrencd Part3 as appears by the Difcntion, commonly obfervcd in the adjacent Parts of the Difeafe. MOREOVER, a Gangrene is very dangerous,.becafe it communicates Salts to the whole Mars of Blood, "which ferment it irccgularly, and produce many fad Accidents; for if the Blood is difpofed Operations of SURGERY. 47T fed for a Gangrene, the leaft Part affeaed with that Corruption, is more than fuflicient to infca all the others. A Gangrene occafioned by the Depravation of the Fluids, which run through all Parts of the Body, is the moft difhmal, cfpecially in an Old Man, becaufe his Blood being deftitute of fpirituous Parts, and its Principcles being no longer duly combined to. gether, it is like a Mars without Motion, very capable of Coagulation And the Remedies, that are moft proper to animate the Blood, not being able to alter fuch a Blood; it follows that this Difeafe muft needs be mortal to People of fuch a Confliturion. This is daily confirmed by Expcrince; and I faw a Woman at the Hotel-diL u, affcdcd with a Gangrene in her Foot, though no external Caute, nor any Diforder in the Solids, could be alledged for it. Mr. Thibaut cut off her Leg; and immedi-tcly all the Veffels appeared full of a thick coagulated Blood: Not one Drop fell to the Ground, though the Tourniquet was wholly unbraced. The Surgeon drefed that Woman with Plagets dipt in Spirit of Wine camphered, and every two Hours fhe had Cordial Potions Pivcn her to reviverc her Blood. All thofe Remedies proved of no Ufe. The next Day the fame Surgeon cut off her Thigh; and the Blood appeared the fame flill. At laft fIhe died two Hours after. THE Gangrene which proceeds from the Depravation of the Fluids, occafioned by fitting up late, by a Repletion, violent Excrcife, and the Ufe of too hot Liquors, is not rfo dangerous as that, which is the Confequence of Sorrow, hard Study, and the Ufe of too cold Aliments, bccaufe in the latter Cafe, the Blood is worfe, and cannot be fo well reflored to its former Concition. WHEN 476 A Treatfre of the WHEN a Gangrene is occafioned by the Diforder of the Solids, it is more or lefs dangerous, according to its different Degrees; for when that Difcafe is only a Gangrene properly fb called, I mean, when it affeds only the Skin, the Fat, and the Membrane of the Mufcle, it is not fo dangerous as when the Part is affeded with a Sphacelus, fince it may frequently be cured without proceeding to the laft Remedy. But when the Body of the Mufcle, or the Tendon, is gangrened, there is no other Remedy but Amputation. WHEN a Gangrene happens in the Opening, or Ligature of the large Veffels, as it happens in Shot Wounds, or in an Aneurtfm, Amputation is the only Remedy left. THE Gangrene, occafioned by a greawCold, which fucceeds a great Inflammation and Contufion, is not very dangerous; for, its Caufe lies only in the Part; 3 and the Mats of Blood is not vitiated; 5fo that it may be cured with proper Remedies. LASTLY, That Gangrene, which happens upon fcirrhous Tumors, diftended Glands, Luxations, and Fradures, and is a Confequence of the Compreflion of the Veffels, as it happens to thofe who lie too long upon their Backs, I fiy, that Gangrene is more or lefs dangerous, as its Caufe is more or lefs maý lignant. Of the Culre of a Gavgrcne. -SINCE I have laid down two general Caufes of a Gangrene, one that concerns the Depravation of the Fluids, and the other, the Diforder of the Solids, we muft ufe thofe Remedies, that defitroy the Caufcs, as much as can be. done. The firft will a6t u poll Operations of S R G F R Y. 47 upon the Blood to reftore its natural Fluidity, and will be the moft proper internal Remedies. The others will work upon the Part it felf, to free it from extraneous Bodies, and will be external Remedies. WE have already feen, that a Gangrene, occafioned by the Depravation of the Fluids, proceeds from many Cauics, and that according to thofe Caufes, the Blood and the Lymph are of a different Conftitution; from whence it appears, that different Aliments or Remedies ought to be ufed. If the Blood and Lymph have been vitiated by fitting up late, &c. Aliments, that fweetcn the Blood, and pafs eafily muff be prefcribcd in order to reftore it. IF hard Study has impaired the Fluids, it is "well known that4he Humors of fludious Men are thick, and do not circulate eafily; and therefore Aliments and Remedies proper to put the Fluids into Motion ought to be prefcribed to them. IF a Gangrene attends a great Hemorrhagy, Weaknefs, and fuch other Symptoms, as may eafily be forefeen, will be the Confequence of it; In order to remove fuch Symptoms, thofe Remedies that are moiftening, light and very nourifhing, are preferred to others; but they ought to be taken in fmall Quantities and often. IF a Gangrene proceeds from a Repletion, Evacuations of feveral Kinds will corrc& it. Laftly, thofe who have taken Aliments either too cold, 'or too hot, will be eafed by contrary Remedies. EXTERNAL Remedies muff alfo be adapted to the Caufes of a Gangrene. For Inftance, fcorbutick People are fometimes fubjed to a dry Gangrene; and the anti-fcorbutick Remedies arc the beft. If a Swelling, and a Diftention have occafioned the Gangrene 478 A Treatie of the Gangrene, emollient, and foftening Remedies ought to be ufed preferably to all other and becaufe I iuppofe a Swelling, Phlebotomy will prove very ufeful ini that Cafe. IN order to make external Remedies effe&iual in moft Sorts of Gangrenes, the Part muft be opened with Incifions or Scarifications upon the whole Extent of that Difeafe. THOSE Operations being performed according to the Method I fhall propofe hereafter, are attended with a fpeedy Succefs, and feem to work Wonders, by preferving the Life, of a Limb, for thefe three citential Reafons. I. Becaufe they unbrace the Part, and fet it at Liberty. 2. Becaufe they expel the vitiated Juices, which are the Caufe of the Difeafe. 3. Becaufe they enable the Surgeon to apply the Remedies immediately to the Difeafe. THE deep Incifions or Scarifications, that are made upon the Extent of a Gangrene, unbend the Part, and fet it at Liberty, becaufe they open the Skin, the Aponeurofcs, which ferve infiead of common Membranes, and the Membranes peculiar to the Mufcles, which by their extraordinary Diftention choak up thofe Organs, and flop the Fluids in them. THEY expel the coagulated Juices, not only becaufe they open a free Paffage for them, but alfo becaufe they very much relax the different Veffels, and by that means facilitate the Reflux of the Spirits which the Brain affords, and the Blood which is continually impelled by the Heart; and thofe Fluids expelling from the Part thofe that are feparated and corrupt, refume their ufual Courfe, their Motion of Fermentation. Thirdly, They make way for the Remedies to reach the very Bottom of the Operatio;s Vf SURGER Y. 479 the Difeafe which is no fniall Advantage, fince the fpirituous Liquors that are made ufe of; irritate in that Place, all the fmall nervous Fibres, which were, if 1 may fay fo, buried under the coagulated Juices, that are the Caufe of a Gangrene, and by thofe Irritations bring the Spirits plentifully into the Part; whereby the Blood acquires a greater Motion, and confequently the Heat is very much encreafed. In order to make dexteroufly thofe Incifions or Scarifications, which I think fto feful, the Surgeon takes a firait Bfiouri, or one fomewhat crooked. I hiould like the latrtcr better than the other. He drives that Infirument as deep as he thinks fit, according to the Incifion he defigns to make, and then cuts the Skin and Fat about the Length of three or four Inches, in proportion to the Bignecfs of the affeated Part, He muff make ficveral Incifions on the Side of the firit, and in a Parallel Line; by which means there will be a Row of longitudinal Incifions or Scarifications. The fecond Row of Scarifications muff bcgin about three or four Inches above the Firitf; and the Surgeon ought to contrive Matters fo, that the lower Angle of each Incifion may end between the two upper Angles of the two firlt Incifions, that they may all engage one with another. IF the Surgeon thinks fit to make a third or fourth Row of Inciflons, he muff always begin thenm above the laft; and if the firft Incifions do not appear to him long enough, he inlarges them by the lower Angle of each Scarification. IF I begin thofe Operations with the lower Part of the gangrened Body, it is in order to prevent the Blood, that comes.out, from diflturbing the Surgeon in the fecond and third Row. BESIDES 480 A Treatfe of the BESIDES thofe longitudinal Incifions, the Surgeon muft alfo make tranfvcrfe ones, efpccially in thofe Parts, that are bounded by the Aponeurofes, fuch as the external and hinder Part of the Thigh and Leg, the external and hinder Part of the foreArm, and along the Back and Loins. THESE tranfverfe Incifions have a fpeedy Succefs, becaufe they cut all manner of Ways the aponeurotic and membranous Fibres, which bind too tight the Mufcles wherewith they are covered, and by that Means facilitate the Circulation of the Blood and Spirits. WHEN the Part is thus relaxed by Inciiions, and the thick Juices, which arc the Caufe of the Difcafe, have a free Pafiage, the whole Limb ought to be fomented with hot and fpirituous Liquors, to revive the Spirits. Such are warm Wine mixed with Brandy, camphered Brandy, &c. Spirit of Wine camphercd or heightened with Salt Armoniac, is an excellent Remedy; and it has often revived the 1Fefh, which feemed to be quite dead. It has that good Effect, by entangling with its fulphurous Particles the coarfe Salts, which diffolve the Part; for the fame thing muff happen by the Mixture of Brandy with the corrofive Salts of the Gangrene, as by its Mixture with the Spirits of Nitre, Salt, and the Lapis Infernalis. And becaufe it wonderfully foftens the latter, and hinders them from making upon the Body the violent Impreffions which they made before the Mixture; it ought likewife to be inferred, that mixing with the corrofive Salts of the Gangrene, it intangles them by its pliant Filaments, and makes their Surface even, which was before uneven. Befides, one may very well believe that Brandy, by its acid Volatil Particles, with the acrimonious Salts, breaks them, leffens their Bulk, and Operations of SUR GERY. 4.8 confequently difables them from working upon and diffolving the folid Parts. We infer, that Brandy works in fuch a Manner, becaufe it has been obferved, that the Blood was coagulated before the Application of Brandy, and that it was difolvcd,and refiumed its former Fluidity, after the Application of that Liquor, which nccflfarily fuppofes a new Fermentation. CAMPHIR-, or armoniac Salt, added to Brandy, contains volatile Salts, which irritate the finall nervous Fibres, laid open by the Incifions, whereby the Spirits run into the Part in a greater Quantity The Spirits mixing with the coagulated Blood, divide and put it into Motion, and by that Means occafion a Separation of the dead Part from the found. WHEN the aiffided Part has been fomented with all thofe Remedies, the Surgeon applies upon it refolutive Poultices, which muff not be taken off every Hour, nor every four Hours; but they ought to -be moiftened with the Fomentations that have been ufed; and the Patient muff be drefled at moft once in four and twenty Hours, unlefs it appears that the Gangrene makes any Progrcfs, which will be known by a concentered Pulfe, a Difpofition to a VDelirium, and by a wild Look and fparkling Eyes. Bur if, notwithftanding all thofe Remedies, the Part grows more infenfible, colder, and fofter, and it appears that the Gangrene is in the Body of the Mufcles, Remedies can no longer be depended upon; 'tis a dead Part, and Amputation is the only Way left to fave the Patient's Life. I i CHAP. 482 A Toeatife of the CHAP. XL VIII. Of the Amputation of the Leg. ESIDES all the Caufes of a Gangrene, which I have mcntioned in the foregoing Chapter, there happens alfo fo great a Diforder in the Solids, that it cannot be removed but by the Amputation of the Limbs. Thofe Diforders are, great Fradures of Bones, an incurabcle Caries, enormous Exoftofes in the Articulations, and Fiffulas in thofe fame Parts, which could not be cured by the moft proper Remedies. THE Fradurcs of Bones happen feveral Ways, either from the Blows of many Sorts of Infiruments, or by Falls;3 but a Limb ought not to be cut off by Rcafon of thofe Accidents, unlefs a very skilfil Surgeon be fully perfuaded, that the Difeafe cannot be removed any other Way. He muff therefore thoroughly examine the Nature of a Wound complicated with a Fraaure. If the Tikia, for Infiance, is broken into feveral Pieces, if the Splinters are funk into the Mufcles and Tendons, if they prick fome Nerves or Blood-Veffcls, the Want of which may occafion a Gangrcife; lafjly, if they cannot be reftored to their natural Place; 'tis plain that a Wound of fuch a Nature can only be cured by cutting offthe Leg. BUT if there was, for Inflance, a Wound complicated with a Frature in the middle Part of the Tibia; if that Bone is broke obliquely, and if even, there is a fmall Notch in its hinder Part, occafioned by the Fratuire, I ask Whether the Leg ought to ble cut off? IF Operations of SURGVRY. 483 IF we believe fonie Surgeons, whofe whole Learning confifts in the Drefings, who are not able to reflea upon the Strucure of the Part, who have not a fufficient Genius to find out new Ways of curing Difeafes in difficult Cafes, and judge of the Dexterity with which fome drefs certain FraCtures, only by the Effeds, without enquiring into the Caufes of the ill Confcqucnces, which fomcrimes happen; I fay, if ve believe thofe Surgeons, we fhall quickly cut off that Leg. BUT if we confult thofe learned Surgeons, who have frcquently demonftrated all the Springs of the human Machine, they will tell us, that Bones may be reunited, as well as the other Parts, and that there are only two eflential Things requifite for that Reunion: The firti confifts in keeping the two Pieces of a Bone one againft the other; the fecond requires a good Conftitution in the Patient, and a perfed Willingnefs to be ruled by the Surgeon. BUT if the Fradure is fich, that the two Ends of the broken Bone cannot remain againft one another, like that which I have inftanccd, by Rcafon of the fmall Notch, which I fuppofe to be in the hinder Part of the Bone; Mr. etit, in tuch a Cafe, made a Hole in the Fore-part of each End of the Bone, and put a fmall Ivory Blade upon the two Bones brought near one another, and kept them fo, with the Help of two fmall filver Screws. By that Means he imitated, with refpeft to the Bones, the quilted Suture, which is commonly made in the tranfverfal and deep Wounds of the great Mufcles. He ordered the Patient to take nothing but Broth every three Hours, and not to ftir in his Bed; but the Patient did not mind that Prefcription; for when the Surgeon thought he oai rvycd a regular li Diet, 484- A Treatife of the Diet, he eatf a great deal of Soop and Meat, and drank Wine; which occaftoned a gathering of Matter all along the Leg and Thigh, which fo difordered the Conftitution of his Blood, that it could not afford a glewy Juice to form a well-conditioned Callus. I muff farther add, that the Patient was always ftirring, and continually difplaced the two Pieces of Bone, which were kept together with the Help of the Ivory Blade and the fmall flver Screws. IF it be abfolutely neceffary, in order to form a Callus, that the two Ends of the broken Bone be fet againft one another, and that the Patient fhould obfcrve a very regular Diet; one may very well believe, that this Patient was far from being cured: However, that Method, which is very ingenious, ought not to be laid afide, in order to refolve upon the Amputation, which is frequently the Refuge of Ignorance. And, indeed, is it not more glorious to drefs a Patient half a Year, and preferve all his Limbs, than to deprive him of one of his Members, that he may be cured in fix Weeks? THE Amputation of the Leg is more perplexing than difficult; it is perplexing, becaufe the Apparatus proper for it is great, and becaufe it requires a great deal of Attention, and a great Prefence of Mind. To avoid failing in any Circumftance of that Operation, our Authors advife the Surgeon to fend for an able Man, who will put him in Mind of many Things which he might forget, for Want of fufficient Attention; for it is much better that a Surgeon fhould fhare with another the Honour of an Operation, than if he ihould perform it wrong alone. BEFORE the Operator proceeds farther, he muff difpofe Operations of SuR GER Y. 48 5 difpofe the Drefling, and fet it upon a large Difhi He lays, firft of all, upon that Difh, what will be ufed lait; wherefore he begins with three or four Comprefles, two Inches broad, and about a Foot and a half long; which is the Reafon why they are called Longuettes. THOSE Comprefles being crucially laid upon the Difh, are afterwards covered with a Comprefs of a fuitable Sizc, and cut in the Shape of a 2alta Crofs. Above that Comprefs the Surgeon lays a fnall fquare one, and above the latter he commonly lays a large Plaget of Flax dipt in a Liniment made with Whites ofEggs, O/eumRofatum,and a littleVinegar; he flrows that Plaget with Bole Armoniac, or Colophony; but I fhall not ufe thofe Ingredients; and inftead of the flaxen Plaget, I prefcribe, a large Lint-Plaget of a round Figure; for fome Reafons which I fhall mention hereafter. ON the Side of that large Plaget, the Surgeon lays two finall ones, of a round Figure one of them, which is very little, is put upon the Perone, and the other, which is larger, is applied upon the Tibia: Afterwards the Surgeon lays near thofe Plagets a fmall Comprefs, thick enough to prefs hard upon the VefiTes upon which it is applied; and it muft not be above an Inch broad, that*it may be placed between the two Bones. He muff not forget to put upon that Drefling, Buttons made with Vitriol pulverized, furrounded with Cotton, and two or three Dozels and fquare Compreffes to lay them, upon Occafion, on the Veflels, that are too fmall to admit of a Ligature; laftly, the Surgeon puts upon the Difh two Lifts of a fuitable Length and Breadth, as I fhall fay hereafter one of which mufft b rolIWd with one Head and the other with two. i 3 IT 486 A Treatife of the IT will not be improper to have ariother Dilh, and to lay upon it the Inftruments proper for that Operation, fuch as a thick Comprefs two or three Inches broad, and five or fix Inches long, to comprefs the Veffels, that the Surgeon may fecure the Blood during the Operation; another circular Comprefi to fatllen the firft 5 the Noofe which ought to be long enough to be laid folded on double; theTourniquet, which is commonly a fmall Box Stick, like a Biltboquet, which is a fmall Stick upon which Periwig-makers curl the Hair, only with this Difference, that it is two or three Tinmes bigger. A fi4all round Piece of Horn, Pafteboard, or Leather, to put under the Tourniquet: Another Noofe to keep the Flcfh tight; a crooked Knife a fmnall firait Knife, not above an Inch broad, only with one Edge; crooked Ncedles, threaded with Fillets, like thofle I have defcribcd, fpeaking of Sutures: Sciffats a Razor; and many other Things; according to the different Operators. ALL thofe Circumftances being duly obferved, the Patient mufi be placed upon an eafy Chair, or upon the Edge of his Bed half bent, and fupported in that Situation by a Servant, who ihall be upon the Bed, and behind the Patient; two other Servants fhall fupport the Limb that is to be cut off; the firft being on the external Side of the Thigh, Ihall hold up the Limb with both Hands towards the Knce; the fecond, being over-againft the Patient, upon one of his Knees, ihall fupport the lower Part of the Leg, in a Line parallel to the Thighr ý llly, a fourth Servant fhall give the Inflruments to the Operator. WHEN the Surgeon has well prepared the Affarftu:s, placed the Patient c0nvenicntly, and the Servants Oplerations of SURGERY. -87 Servants in a proper Station; lie muff firift of all fhave the upper Part of the Leg, from the Knce to that Place where it muff be cut off, which is generally under the Tuberofity of the Tibia I mean fix Inches above the Knee. I thall lhew hercafter the Ufefulnelf of fiich a Precaution; and if Surgeons are advifed to cut off the Leg under the AponeuroJis of the Mufcles, halfncrvous, and half nmembranous, and of the Gracilis Internues; it is in order to avoid Convulfions, Inflanmmations, and long Suppurations, which have frcquently happened after the Cutting off the Apoijeuro/is of thofl M ufcles. FoR the right performing of that Operation, the Surgeon ought to mind four efln-tial Things: The firft confifts in preventing ana Effuflon of lJood during the Operation: The fecond. in preferving tht Skin as much as pofliblc: The third, in extirpating the Limb: The fourth, in Iecuring the Blood after the Operation. To put in Execution the firit effential Thing, the Surgeon being placed between the Patient's Legs, and having a Napkin about him to wipe his Hands conveniently, fball take the finall longitudinal Cuifhion, or the thick Comniprefs above defcribed, and place it under the Ham, that being the Place where the Veffels pafs, being only covered with a little Fat and the Skin. He muff then take Care that the Leg be a little bent, that the Bones may not lie open, when it is cut off. THE Surgeon muff alfo take Care, that the Cu. Nhion, or Comprefs, be of a certain Figure, and that it may be conveniently laid between the Tendons of the Inflexors of the Leg. Thofe Mufcles, on the external Side, are the Biceps, which is inftmed in the upper and external Part of the Rerone; Ii 4 an+d, 488 A Treatife of the and, on the. internal Side, the half nervous and membranous, and the GracilisInternus, which are inftrtcd inwardly in the upper Part of the Tibia, under its Tuberofity by a common Aponeurofis for if that Cufhion leaned upon thofe Tendons, they would be fo much compreflfd, that the Lymph and Blood circulating in their Fibres, might extravafite, and occafion Inflammations, Gatherings of Matter, and Abfcleles, whereby the Patient's Life would be in great Danger. 1 HE Surgeon muft fupport that Cufhion with a Conprefs long enough to make one Turn and a half about the Circumference of the lower Part of the Thigh. Afterwards, he fhall lay over that Comprefs the double Noofe, which muff be flopped in the Fore-part of the Thigh, above the Knee, with a fingle Knot and a Loop; taking Care to leave a Space, in order to convey the round Piece of Horn, Pafiboard, or Leather, and the Tourniquet, which muft be braced, whilft the Surgeon cuts the Flefh and the Bones. THE ufual Tourniquet, which I have dcfcribcd, is liable to feveral Faults, that frequently prevent the Succefs of the Operation, by the Accidents which it occafions afterwards. FirJl, it flraitcns equally the whole Circumference of the Limb, that is to be cut off, which hinders the Blood from running through the collateral Veffels, for the Nourithmcnt of that Part, which ought to be preferved. Secondýy, it pinches the Skin, becaufe the Patient, affedted with the Fear of the Operation, gives no Notice of it. Thirdly, it muft be held by a Servant, who being ignorant of the Operator's Views, will firaiten it too much or too little. I add, that a great Number of Servants is no inmall Obitcle in the Operation. To Operations of SUR GERY. 489 To prevent all thofe Accidents, the ingenious Mr. Petit invented a new Tourniquet, confifting of an Iron Plate, half circular, in the Middle of which there is a Button, on the Side of the Convexity, and fpiral Grooves are contrived in that Button to receive a Screw. That Plate is covered with Ihammy Leather, excepting the Button; and at the two lower Ends there are two finall Cuihions, to avoid bruifing the Sides of the Member. To that Plate another is adapted, which is not half fo large, and is pierced in the Middle, to let out the Button of the firft. AFTERWARDS the Surgeon ufes a Cufhion ofrolled Linnen, covered with fhammy, and tied to a Boot-Leather likewife covered with fhammy; and behind he fows a Noofe folded double, which makes at one of the Ends a Handle four IncheS long, and at the other the two Extremities of the Noofe hang dowi. IN order to apply that Tourniquet well, the Surgeon puts the two Plates adapted together about the Thigh, and above the Knee, the Button being oppofite to the Ham: Afterwards he applies the Cufhion upon the Veflfls, between the Tendons of the Inflexors, and conveys the Handle and Extremities of the Noofe above the Plate, to ftop them with a Knot and a Loop, and then with the Help of the Screw he removes the two Plates from one another; by which Means the Cuihion is very much ftraitened, and confequently the Veffels are compreffed. The Screw of that Tourniquet having too fmall Threads, Mr. Petit orders it to be made of Wood; fo that half a Turn of the Screw is fuffi. cient to make a great Compreflion. THE Ufefulnefs of that Tourniquet confilts in feveral 490 A Treatife of the veral Things: Firfl, It is not troublcibme when it is applied. Secondly, It may be kept on as much as one deftrcs after the Operation. Thirdly, There is no need any Body fhould hold it; for the Operator may loofen or firaiten it, as he plealfs. Fourthly, It flops the Blood very well. THE firft effential Thing being done, the Surgeon firetches out the Patient's Leg, and bids a Servantdraw the Skin over the Knee,, in order to. preferve as much of it as pofliblc, to cover the Stump. Afterwards he makes a Ligature \with the fecond Noofe, under the Tuberofity of the T;bia, in that Part where he defigns to cut off the Leg, that he may the better coniblidate the Fleh, and facilitate the Operation. To perform the third efifential Thing, which confifts in the Manner of Extirpating the Limb, the Su rgeon covers all the lower Part of the Lcg and the Foot with a Napkin; and being upon one of his Knees, he conveys his right Hand under the Patient's Leg, to take the crooked Knife from a Ser-. vant placed on the external Part; and having the Handle of the Knife in his Hand, he lays the Edge of it upon the internal Angle of the Tibia, as inwardly as he can, and claps the Fingers of his left Hand upon the Back of the fame Knife, to keep it more even. THE Operator muft hold the Knife ftrait, that is, not more inclined on one Side than on the other,and take care not to prefs hard upon it, when he goes over the Spine of the Tibia, for Fear of turning the Edge of it, and fo fpoiling it for cutting the Flefh neatly. When he has cut the Skin that covers the Tibia, he cuts the Flefh in the external Part of the Leg, conveying the Kcife towards the hinder Part Operations of SUR G ERY. 49 1 of that Limb, that he may cut with greater Strength, the Gemini and the Gaflrocnemia; and ftanding up, he brings up the Knife to cut the internal Part of the Leg, as far as the Place where he began; and thus making a circular Turn, he cuts the Skin, and all the Flcfh to be found in tht Circumference of the Tibia and the Perone, excepting that which lies immediately between the two Bones. Some Surgeons advife in the next Place to convey a difmenbring Knife into the circular Incifion, in order to cut the Flefh left uncut by the great Knife: But when the Operator ufes a good Infirument, and is not too hafty, he has no Occafion for the difmem. bring Knife. Now the Surgeon muff cut the Flefh and the Veffels that lie between the Bones: In order to it, he takes a fmall ftrait Knife, or a firait Bifouri, which he drives between the two Bones, turning the Back a little towards the Part he defigns to preferve; for if he turn'd the Edge that Way, he might fplit the Vcf'els, and he would be at great Pains to flop the Blood. Before he quits that Inflrument, he muff fcrape the Periofleum, lying upon the Spine of the Tibia, and take Care always to fcrape off the Periofleum upon the Part that is to be cut off. AFTERWARDS the Surgeon ufes a Piece of Linnen, one Inch long, or more, and five or fix Inches broad: He fplits that Linnen at one End as fat as the third Part of it, and applies the two Heads of that Linnen about the Bones, one o0neach Side. He croffes thofe Heads in the hinder Part of the Leg, and bids a Servant draw them up, as well as the End of that Linnen, which I frippofe to be in the inter, nal Part, and which is not cut, By that Means, thý Surgar withdrxws th kth and the BoAes lyin PTore 492 ATreatife of the more bare, he is at Liberty to cut them farther, and may cover again the Bones more ipeedily. IN order to taw the Bones, the Surgeon takes the Saw with his right Hand, and laying his left Hand upon the Leg, he forms the firli Traces of the Saw upon the external Angle of the Tibia, as near the Linnen that raifes the Flefh, as he can poflibly do it. Herein I feem to run counter to Ibme Mcoderns, who advife to faw the two Bones at once, beginning with the Perone. I am perfwaded, that if the Operator began to form the firft Traces of the Saw upon the Perone, he would run the Risk or fpintring it, or occaftoning a TDiaftafis in it, becaufe it is very weak, and can make no great Iefiilance to the Saw: That Method would produce Gatherings of Matter and Abfceffcs, which perhaps would prevent the Succefs of the Operation: But if the Operator forms the firft Traces of the Saw upon the Tibia, he runs no Risk, fince it is firong and folid. Afterwards he inclines the Saw a little towards the Perone, and fawing them both at once, the Tibia ftupports the Perone; however the Surgeon nmufl taw the Perone in the firft Place, and end with the Tibia, bidding the Patient let down his Leg a little, in order to facilitate the Effet of the Saw. WHEN the Saw has formed a Circle round the Bones, the Operator mutl faw them very faft, and not flowly, as fome do; but Care ought to be taken to do it with a light Hand; for when the Saw lies hard upon the Bones, its Teeth get into them, and flop it and then the Surgeons take a great deal of Pains, and yet only faw as it were by Starts. THE fourth effential Thing, in the Amputation of Limbs, being, as I have already faid, to prevent an Effufion of Blood after the Operation, the Surgeon nmft Operations of SURGERY. 49 3 muff take off the fecond Noofe, which had been applied under the Tuberofity of the Tibia, to keep tight the Skin and the Flefh; afterwards he bends a little the Thigh and the Stump. He himfelfloofens a little the Tourniquet, if he ufes that which has been invented by Mikr. Petit; but if he ufes the common Tourniquet, he bids a Servant loofen it, by turning it back half way round, that he may know, by the coming out of the Blood, where the Arteries lie. Affoon as he has well obferved the Place, he takes the crooked Needle threaded with a Fillet, and makes two Pundions on the Side of each Artery, without cutting the Fillet, one above the upper Part, and the other under the lower; ol that thofe twoPundions will make fourOpenings, like a Square, in the Middle of which the Artery and other Vcflels will be found. THE Surgeon muff flop with Knots the two Ends of the Fillet, one of which is at the Entrance of the firft Pundion, or of the firft Stitch, and the other at the coming out ofthe fecond: Afterwards he cuts them at four Inches Diflance from the Flefh. The Surgeon mufft take Care to drive the Needle far enough into the Flefh, in order to fecure the Tightnefs of the Veffels, and comprefs them more exa&ly: He muff do the fame Thing in all the Arteries, being careful to loofen the Tourniquet, that he may perceive them, and to flraiten it, in order to make a Ligature upon them. He muff particularly mind an Artery,which is commonly in the Gemini, and often emits Blood two or three Hours after the Application of the Drefling; and therefore the Surgeon is not to put on this Dreffing too haftily, and muft take great Care to wipe the Stump two or three Times (the Tourniquet being quite loofe) in order to fee whether the Blood be well flopped. HA. 4-94 A Treatife of the HAVING thus explained how the Amputation of the Limbs ought to be made, I proceed to the Dreffing of the Patient: The Surgeon muff bend the Stump, and draw the Flefh and the Skin about the Bpones, as much as he can. Afterwards he lays upon the Veffels lying between the Bones, a narrow 4nd very thick Comprefs; the two fmall dry Plagets upon the Bones, fmall fquare Compreffcs upon the other Ligatures, and upon the Whole fome Plagets of different Figures, to comprefs in every Part. WP might with the fame Intent lay over thofe Plagets fome coarfe Lint, without any Figure of Plagets or Dozels. 'Tis true, that by fuch a Method we depart from the Praaice of many Surgeons, who chide the Servants, when they bring Plagets that are not neat and in good Order; but that Regularity of the Plagets does not fit fo clofe upon every Part as when they are fhapclefs, and the Lint is without any regular Order. SURGEONs do alfo commonly tife two flaxen Plagets, one covered with Colophony, and the other with Bole Armoniac, and over thofe large Plagets covered with aftringent Powders, they farther lay a Hog's Bladder. All thofe Remedies are ufclcfs, very perplexing, and even hurtful: I hey are uiliefs, fincethe Lint alone is an Afiringent and Abforbent, which anfwers all the Indications. It is well known, why all thofe Applications are perplexing; and therefore I need not dwell upon it; but it is not improper to know, that thofe Powders are extraneous Bodies, which occafion Obfitru&ions, Inflammations, and fometimes the Confequences of thofe Difeafes; Befides, they retard the Suppuration, and itick fo clofe to the Circumference of the Stump, that tis ctreamly difficult to take them off, as I have -Operations of SURGERY. 9i have often oblcrv'd, fo that the Stump ble4 on all Sides after the removing of thoie Aftringents. I HAVE feen that Operation performed4 by Mr. Petit, who only ufes more Plagerts, in the Ma4er above-mentioned; and on the third Day the Suppuration was come to a Head, the Plagets falling off themfclves, without any Need of pulling them, as muff be done when the Plagets are made ofFlax. AFTER the Application of the Plagets;tthat $4rgeon advifcs us to ufe a Plaifler made like a T, with four Heads, covered at the End of thofe Heads witi the Plaifter of Andreas a Cruce, to draw the Skin and the Flefh over the Bojes. If I have faid that the Hair ihould be ihaved before that OppcratiQn, 'tis in order to prevent that Plaifler, which is a powerful Agglutinative, from flicking to it, and occafioning P4in when 'tis taken off. The Surgeon lays over the Plaifler a fquare and thick Comprefs, iot exceeding the Circumference of the Stump; he covers it with the double Comprcfs made in the Form of a Aalta Crofs; he applies one of the Arms of it under the Ham, and the Middle of the Crofs paffing over the Stump, the oppofite Arm is applied upon the fore and upper Part of the Leg, &c. AFTERWARDs the Surgeon applies the longitudinal Compreffes, which muft not be very broad, to make 4 firong Comprcffion. He reverles one End of the firit, about four Inches upon its Body, and qpplies that reverfed End to the hinder and upper Part of the Leg; he other Head of the Comprcfs, paffirng over the Stump, comes upon the Kne. Afterwards the Surgeon takes the fecond longitudinal Cpnmprefs, with both i-lands, by its two Ends, and pplies the Middle of it upon the Stump, conveyip the lcads all alonig tli Sides of the Leg, to crofs gbove 496 A Treatife of the above the Knee. Lafftly, he applies the Middle of the third longitudinal Comprefs immediately upon the hinder Part of the Leg, on the Edge of the Stump and then he proceeds to crofs in the fore Part, from whence the Heads being conveyed upon the Sides of the Knee, crofs one another above it, where they are flopped. That whole Drefling is fupported by the following Bandage, called the Capeline with one Head. Of the Bandage called the Capeline with one Head. THE Roller that is to be ufed for the Capeline with one Head, in the Amputation of the Leg, muft be three Inches broad, and about fix and thirty Foot long. THE Surgeon begins that Bandage with two circular Turnings upon the Edge of the Stump, to comprefs the Flefh and the Fat, which fwell affoon as they are expofed to the Air. Afterwards he proceeds by Edgings to the Knee, and when the Globe is in the external Part, (I fuppofe the right Leg has been cut off) he conveys it above, to pafs laterally and internally upon the Middle of the Stump. In the next Place he conveys theGlobe of the Roller upon the Knee, paffing upon the external Side of the Stump; from thence he defcends internally to pafs a fccond Time direftly upon the Stump, taking care that this laft Turning may crofs the foregoing obliquely: He afcends upon the Knee, about which he makes a Circular to defcend anteriorly and laterally, from above downwards, upon the Stump, taking care that this third Turning may ftill crofs the. firft obliquely; fo that thofe three Turnings reprefent a Stole, which is not only very neat, but alfo Operations of S GER Y. 497 tlfo makes a confidcrable Compreflion. Afterwards he afcends upon the Knee to convey the Globe under the Ham, that he may dcfcend all along the hinder Part of the Stump, and pafs direfly over it, by crofling with the firft Turning. Afterwards he conveys the Lift upon the Knec, pafling along the fore Part of the Stump, whiere he inverts it, if he plcafes, to crofs again twice upon the Stump, or fill up the Vacuities. LafTly, he afccnds again upon the Knee, from whence he defcends obliquely to the lower Circumference of the Stump, where he makes one or two circular Turnings, and then he afccnds again obliquely to the upper Part of the Thigh, which is generally uncovered. THE Circumvolutions of the Lift reaching from the Knee dircdly to the Stump, arc called the Turnings of the Capeline; thefc muff be very tight, becaufe they comprefs the Veffels directly. The others, on the contrary, which we call Circulars, being only ufed to encompafs the firit, need not be fo tight by a great deal, AFTERWARDS the Surgeon lays down the Patient, and places his Stump upon a Cufhion fomewhat raifced; A Servant flays by the Patient, and lays one of his Hands upon the Stump, and the other upon the Knee, to comprefs the Dreffing diretly upon the Veffels. SOME Praditioners advife to put a Comprefs, a Noofe, and a Tourniquet, upon the internal Part of the Thigh, in order to ufe it, if the Blood Ihould come out, whilft the Operator is fent for. THE Patient mull keep to a ftri6t and 'egu lar Diet, and be blooded more or lefs, accdrding to his Strength; for if he be of a fanguine or bilious Conflitution, he ought to be blooded four or five K k Times 498 A Treatife of the Times the firft Day, and twice, at leaft, the fecond Day. By that prudent- Method Patients frequently fave their Lives, who would otherwife fall into Convulfions, and a cDelirium, which would occalion their Death; as it happened to the Sailmaker of the Ship, called the Count of Touloufe, where I was one of the Surgeons.. And if the convulfive Motions, either of the whole Body, or of the Part, break the Arteries, and make them reafcend, Prafitioners advife, to apply immediately a Button of Vitriol upon the Part, to prefs it well with Compreffes and Lint, and fo on with the remaining Part of the Dreffing, as I have faid above. To explain the- Caufe of thofe Diforders, it may be faid, that the Spirits, which ufed to run in the lower Part of the Leg, and into the Foot, being flopped by the Sedion and Ligature of the Nerves, are forced to run back into the Brain; and the Irritations are violent, by Reafon of that violent Reflux. And becaufe that Reflux continues, the Spirits will be difordered in the Brain, and confequently will difcompofe all the Animal Fundions. 'Phlebotomy ought therefore to be frequently repeated, in order to abate the Impetuofity of the Blood, and to allay the Ferment of the Humours. CHA P. XLIX. Of the Amputation of the Leg, when Part of it is left inventedat the fame Time by Mr. Sabourin,, a Surgeon ofGeneva, and Mr. Verdevin, a Dutch Surgeon. TH 0 U GH the Amputation of the Leg be moft commonly ufed in the Manner above defcribed, Operations OfSU RGERY. 499 bed, yet the Readers will not be difplcafed to find here a different Method, which is of very great Ufe. To make the Amputation of the Leg, by preferving one Part of it, the Patient muff be placed much in the fame Manner, as in the foregoing Operation. Afterwards the Surgeon applies the Cufhion, with which he is to prevent an Effufion of Blood, upon the internal and upper Part of the Thigh, and the Tourniquet upon the external Part, becaufe it is not fo troublefome in that Place, and muft remain in it 'till the Cure be over. THE Operator being placed between the two Legs of the Patient, takes a firait Knife, whofe Blade is about fix or eight Inches long, and one and an half or two broad, and muft be fharp on both Sides. He makes with it a femicircular Incifion, two Inches under the Tuberofity of the Tibia, and cuts only the Skin and the Fat, that are on the fore Part of the Leg I mean upon the Perone and the Tibia, taking Care not to lean hard upon thofe Bones, to preferve the Edge of his Knife. When he comes to the internal Part of the Tibia, he turns the Knife obliquely to cut, as he defcends towards the lower.Part of the Leg, about one Inch of the Skin and Fat. Afterwards he conveys his left Hand to the external Side of the Leg, to keep the Flefh in its due Situation whilft he pierces it as near the 'Perone and the Tibia as he can; and without ftopping he comes down lower, cutting the Gaftrocnemia and the Gemini, according to their Length, and making of Part ofthofe Mufcles, and of the Skin, a Shred of a triangulat Figure, and about fix or eight Inches long. WHICH being done, he quits that Knife, to take another much narrower, in order to cut the Flefh Sa and 500 A Tretife ofthe and the Vefefls lying between the Bones; They ought to be cut as exadly as poffible to avoid a Suppuration. Afterwards he cuts the Periofleum about the Tibia, fcraping the Bone on that Side on which it is to be cut off. In the next Place, the Operator is to give two or three Cuts lengthwife with the Point of the Knife upon the Extremity of the Bone he dceigns to prefervc, in order to cut the Periofleum, that he may prevent its Inflammation. The fame Precaution ought to be ufed with Refpct to the 'Perone. THE next Thing is to faw the Bones; but becaufe the Shred lies in the Surgeon's Way, he raifcs and fupports it with a fingle Comprefs, fix Fingers broad, and a Foot long; he fplits that Comprefs about two Thirds, and applies its two Heads on both Sides of the Bones, bidding a Servant hold them towards the Knee; and the Body of that Comprefs muft be conveyed and faftened towards the Ham by the fame Servant, to raife the Shred, and fccure it from the Tceth of the Saw. AFTERWARDS the Operator faws the Bones, obferving the Rules above-mentioned, for the ufual Amputation of the Leg; and, aflbon as they are cut, he muft convey his Hand under the Shred, and bring it near the Bones to cover the Stump with it; and therefore he muff cut it, if it be too long, and leften the Flefh, if there be too much of it. Laftly, the Operator muft adapt it to the Stump upon which he applies it. In order to keep always the Shred in that Situation, he may make fome Stitches to it. I think the dry Suture, together with the Plaifter of Andreas a Cruce, would be very proper. I muff obfcrve, that during thofe feveral Operations, a Servant muft always keep his Hand upon the Shred, to move it towards the Stump. IN Operations of SURGER Y. 50f IN order to drefs that Amputation, the Surgeon lays two long Plagets in the Circumference of the Stump, one on each Side, and a Comprcfs in fix or eight Doubles upon the Shred, to prels the Veffels -diretly; He covers that Drefling with a Plaifier in the Shape of a T, with five Heads, and with foime Compreffes of a like Figure; and he fupports the Whole with the following Bandage; that Bandage confifts in making fomne circular Turnings in the upper Part of the Leg, and fbome converted ones tycd with Pins, and conveyed above the Stump. HE leaves the Stump firetched, and puts it into a Kind of Cawl made offhammy Leather, having four Heads in its Circumference, two of which muft be tyed about the Body, and the two others about the Thigh. TiE Surgeon lays the Patient down, and puts the Stump upon a Cufhion; a Servant fitting by him muff always have one Hand applyed upon the Shred, and confequiiently oppofite to the Column ofBlood, that the Flclh being thus propelled may make a more direCt Compreflion than upon the Sides. THE Tourniquet is of great Ufe in this Sort of Amputation, fince the Vcflels are not tyed, and the Compreflion of the Shred is the only Thing that prevents the Iffue of the Blood. The Tourniquet muft therefore be always kept on, and loofened in fuch a Manner, as to let in no more Blood than is neceffary for the Nourifhment of the Stump; which will be known, by laying the Fingers on the hinder Part of the Ham, where the beating of the Artery is felt; and if it be too firong, the Tournigpet muff be braced a little tighter, on the contrary, it muff be gackned a little, when that beating is not felt. K-~k3 'Tis 502 A Treatife of the 'Tis plain, that the ufual Tourniquet could hardly be of any Ufe in this Way of cutting off the Leg, for a Servant could not hold it fo long, in the Degree of Tightnefs or Slacknefs which is ncceffary. On the contrary, Mr. Petit's Tourniquet perfeftly anfwers all Intentions and it may comprefs the Arteries to fuch a Degree, that they will only let in as much Blood as is neceffary for the Nourifhment of the remaining Part of the Extremity; which is of no fmall Confequence, fince the Succc'i of that Operation depends upon it. THiIs Way of cutting off the Leg is attended with feveral Advantages. FirJfl, It affords a fpeedy Cure; fince the Surgeon need only forward the Reunion, and prevent the Suppuration. Secondly, The Patient being cured, can move the remaining Part of his Leg and the Bone forming a Cavity in the Gemini, and thofe Mufcles growing hard, a Man may walk with a wooden Leg, hollow in the Infide, and no Body will diftinguilh it from a true Leg. MR. Petit has feen fome Officers upon whom that.Operation had been performed, who danced and leaped, as if their Legs had not been cut off. IF Phlebotomy is of Ufe in Amputations, it is, doubtlcfs very neceffary in this Operation, fince the Quantity of the Blood and its Motion ought to be leiffned. And becaufe the only Defign of the Surgeon is to procure the Union of the Shred with the Stump, the Plagets muff not be taken off, but only moiftened with fome fpirituous Balfams; and Care muft be taken to have the Shred always reft and prefs upon the Bones. CHA P, Operations of SURGERY. 503 CHAP. L. 'Of the Amputation of the Thigh. Nthe Amputation of the Thigh, as well as in that of the Leg, the Operator mufft firft get the Drefling ready, which differs only from the Dreffing of the Leg, becaufe the Pieces of which it confifts ought to be every Way larger. The Drefling being ready, the Surgeon fets the Patient upon the Edge of his Bed, and ihaves the middle and lower Part of the Thigh, to prevent the agglutinative Plaiffer, that is to be ufed, from flicking to the fmall Hairs, which cover the Skin. Afterwards the Operator, being placed near the external Part of the Thigh, muft mind the four Circumftances, which I have mentioned for the Amputation of the Leg3 the firft of which confifts in preventing an Effufion of Blood during the Operation. To that End, he applies the Cufhion of one of the two Tourniquets above-mentioned to the internal and middle Part of the Thigh, becaufe the Veffels run that Way to go to the Leg. Afterwards he places the Tourniquet in the external Part, and bids a Servant brace it fufficiently, in order to comprefs the Veffels, and ftop the Blood. 'Tis obferved, that the Thigh ought to be in a Line parallel to the Body, that the Mufcles may not leave the Bone bare, after the Amputation. In the next Place, the Surgeon conveys his right Hand above the Patient's Thigh, to take the crooked Knife, which a Servant muff give him between the Thighs, that the Patient may not fee it; he raifes his Hand and Arm Sk 4 to 504+ A Treatife of the to bring the Edge of the Knife near the fore and cx, ternal Part of the Thigh, two Inches above the Knee; for in that Place the Thigh is generally cut off. Afterwards laying the Palm of his Hand upon the Back of the Knife, to make the Incifion with more Strength, he cuts the Flefh circularly, as I have faid for the Amputation of the Leg but if he minds the.fccond Circumftance, which confifts in preferving as much of the Skin as poflible, he muft not obferve that Method of cutting the Skin and the Flefh, fince it always leaves two Inches of the Bone bare; and from the Edge of the Skin to the Edge of the cut Bone, there are five or fix Inches, as I obferved in the Hofpitals, where I faw that Operation performed. IN order to avoid that Accident, which retards very much the Cure of thofe Amputations, we muff follow Mr. Petit's Advice; I mean, that the Inciflon of the Skin and Flefh, which cover the lower Part of the Femur, ought to be made at two fexecral Times. For Inflance, when the Surgeon has placed the Tourniquet in the middle and internal Part of the Thigh, he draws the Skin from the Knee towards its upper Part, and applies a fecond Noofe one Inch above the Rotula, which keeps the Skin from thrinking. Afterwards the Surgeon takes the crooked Knife, as I have juft now faid, and makes a circular Incifion between the Ligature and the Rotula, in which he only cuts the Skin and Fat, 'till he fees the Mufcles; Aiboon as he perceives them, he takes off that fecond Ligature, and gets the Skin raifed by a Servant, who takes hold of the Thigh with his Hand on both Sides; the Operator fees then the crural Mufcle, the Vajlus Inter-?us, and Externus, &c. layed bare under the Skin about Operations of SURGERY. 05 about two Inches. He takes the crooked Knife, and cuts thofc Mufcles circularly, as I have faid, as near the Skin that is to be preferved as poflible3 and by that Means he wili lay open the Bone exadtly in the Place where 'tis ufual to cut it, viz. thrce Inches above the Knee. To obferve the third eflential Circumftance of this Operation, the Surgeon muft take a Comprefs fplit at one of the Ends, as I have already faid, and apply the two Heads between the two cut Pieces of Flefh. He croffes the Heads, and bids a Servant draw them upwards together with the Body of the Comprefs; by which means the Flefh to be preferved, is withdrawn and fecured from the teeth of the Saw. Afterwards the Surgeon fcrapes the 'PerioJfeum, leaving none of it upon that Part of the Bonle, which is to be cut off; and flanding near the external Part of the 'Thigh, faws the Bony with a light Hand though he takes long Stroaks. Laftly, the fourth Circumitance confifts in preventing an Effufion of Blood after the Operation; which will be effcded by making Ligatures in the Veffels, in the fame manner as I have Laid for the ufual Amputation of the Leg. There are three Arteries in the Thigh, wherein tlat Ligature ought to be made. Afterwards the Surgeon flackensthe Tourniquet wholly to fee whether all the Veffels be well flopped, and takes Care to wipe the Stump with fmall Rags, in order to perceive that Part which affords the Blood. BEFORE he applies the Drefling, he mufl bring the Flefh and Skin near the Extremity of the cut Bone; and if he makes the Incifion at two feveral Times, as I have faid, he will have the Satisfaation 506 A Treatife of the of feeing the Flefh level with the Bone, and half covered with Skin. To drefs that Amputation, he lays a Plaget upon the Bone, fmall and thick Compreffes upon the Veffels, a round Plaget upon the Stump, and over that Plaget fome Lint put together without order. Afterwards he lays a Plaifter of Andreas a Cruce, made like a T, with four Heads. He applies the Body of that Plaifter about the Thigh, and croffes the Heads one above another, paffing upon the Stump. Over that Plaifter he lays a fquare Comprefs in five or fix Doubles, the Compreffes in the fhape of a Malta Crofs, and the longitudinal Compreffes, as I have fhewed. Laftly, he fupports the whole by the following Bandage. Of the Bandage proper for the Amputation of the Thigh. FOR the Amputation of the Thigh, the Surgeon ufes a Roller, three or four Inches broad, and about thirty Feet long, with one Head. He begins with two Circulars upon the lower End of the Stump, as I have fhewed for the ufual Amputation of the Leg, and for the fame Reafons. Afterwards he afcends obliquely to the upper Part of the Thigh, in order to put the Globe of the Roller about the Body, and come again to the Stump'; from whence he afcends a fecond Time upon the Stump, croffing there with the firft turning. In the firft Place, he muft convey the Roller to the upper Part of the Thigh, and there makes Turnovers tied with Pins, to pafs again twice upon the Stump, where he fills up the Vacuities of the two firtt Operations of SUJR GERY. 507 firft Turnings; which makes a very good Comprefs in the fhape of a Star. Afterwards he conveys the Roller obliquely upon the Edge of the Stump, where he makes two Circulars, and afcends by Edgings to the upper Part of the Thigh. Lafftly, he paffes about the Body to tic the Roller where it ends. CHA P. LI. Of the Amputation of the Fingers. T H E Antients believed that the Wounds of the Articulations were abfolutely incurable, and prepoffift with that Opinion, they durft not cut off the Limbs in their Articulations. HOWEVER when the Fingers were crufhed, gangrcned, rotten, d&c. they cut them off; but they ufcd very painfull Methods, and -fuch as were frequently unfuccefsful. ALL of them preferibe cutting off the Fingers in the middle of their 'Phalanx's. Some ufcd incifivc Forceps's for that Operation; others put the Finger upon a Block of Wood, and laying a Chizel upon the middle of the Body of the RPhalanx, they firuck one Stroke with a Mallet upon the Head of the Chizel, and fo cut off the Finger. Laftly, others thought the beft way was to ufe fmall Saws, with which they fawed the Fingers in the middle of their Phalanx's. BESIDES the Cruelty of the two firft Methods, and the violent Pain occafton'd by them, they were alfo frequently attended with Accidents, which prevented the Succefs of the Operation; for 5o8 A Treatife of the for fometimes they fplintered the Bones; the Difcafe was followed by very fad Symptoms; and the Cure was long and very difficult. I add, that when the Phalanx's are cut in the middle of their Body, the remaining End is very much deformed, ufelefs and troublefome, cfpecially when 'tis the firft 'Phalanx, I mean that which is contiguous to the Metacarpium. That Inconveniency always happens, when the third Method of the Antients is ufed. To make the Amputation of a whole Finger, if it be the middle one, or the Ring Finger, the Surgeon muft lay bare its Articulation, the Bone of the Mletacarpium, by making an Incifion on each Side with a ftrait Bifouri, penetrating between the Bones of the Metacarpium under their Head. And if it be the firft or little Finger, it will be fufficient to lay it bare only on one Side, as it appears by the Infpetion of the Part. Mr. Thibaut lays,.that Incifion ought not to be made exafly in the middle of two Fingers, but oin the Side of the Finger, that is to be cut off, in order to preferve more Skin, and to procure a Scar lefs deform'd, and a more fpeedy Cure. Afterwards the Surgeon with the fame Bifouri cuts the Finger in the Articulation, taking Care to bend it firit, in order to perceive better the Place of the Articulation, and to preferve its Ligaments more eafily. When the Ligaments of the Articulation are half cut, the Operator firetches or fircightens the Finger without taking off the Biflouri, and makes an End of cutting the Ligaments. If he feels any Refiftance, it is only occalioned by the Sefamoid Bones; and then he mufft cut either higher or lower, without quitting the Head ofthe Bope with the Inftrument, THE Operations of SURGERY. 5099 TInE Hemorrhagy, which happens after that Amnputation, is not confiderable. However, if the Blood fhould come out with Violence, a Ligature might be made. Mr. Petit advifcs afterwards to cut lengthwife the Sheath of the Tendons, at lcaft about an Inch, in order to avoid a Conftriftion, and confequently an Inflammation, and the Abfccfles which happen in the Hand, when fuch a Precaution is not ufcd. THE Drfcling confifts in laying a dry Plaget upon the -lHead of the Bone of the Metacarpium, and over it two or three notched Compreffes, that the other Fingers may find room in the Notches, and they are raifed to a certain Height, that they may be able to make a itrong Compreflion upon the Veffels. ABOVE thofc Comprcffes the Surgeon lays a Sling with four Heads, and covers it with two fmall long Compreflcs applied crofswife. Afterwards he fupports the whole with the following Bandage. Of the Bandage proper for the Amplttation of the Fingers. WHEN the three Phalanx's of the middle or Ring Finger are cut off, the Surgeon, to fupport the Drefling, ufes a Roller that is an Inch broad, and about eighteen Feet long,.with one Head. HE applies the End of the Roller upon the external and hinder Part of the Wrift, and makes two Circulars about it. Afterwards he conveys the Globe upon the back of the Hand to pafs obliquely upon the middle of the narrow long Compreffes, that are applied crofs-wife 5 and then he conveys the Roller into 5 o ATreatfe of the into the Palm of the Hand, to go upon the Thenar, and make a Circular about the Wrift. The Roller being in the fore Part of the Wrift, the Surgeon conveys it obliquely upon the fmall Compreffes, to crofs with the turning already made upon it. Aftrwards he conveys the Roller into the Palm of the Hand, to pafs upon the hinder Part of the Hypotenar, and make a Circular about the Wrift. He makes a Turnover upon the external Part of the Wrift, and conveys the Roller into the Hand, by pafling upon the Wound to form with the two foregoing Turnings a LStar, which makes a ftrong Compreffion; and then he paffes over the Thenar, and makes a Circular about the Wrift, and paffes the Roller upon the back of the Hand, and upon the lower Part of the Bone of the Metacarpium, which fupports the little Finger; from whence pafling tranfverfly under the other Bones of the Metacarpium, he makes a Circular Turning in that Place, which fupports thofc that have been made upon the Wound. Afterwards the Surgeonproceeds again from the Palm of the Hand to its back, to make a K upon the Metacarpium, and make an End with Edgings all along the Fore-arm; taking Care to lay before thofe Edgings fome Compreffes along the Cubitus and Radius, in order to comprefs the radial and cubital Arteries, and prevent their carrying fojmuch Blood towards the Fingers. IT is not improper to blood the Patient, and to prefcribe a regular Courfe of Diet, till the time of the Accidents be over. Glyfters and other Remedies are to be ufed, as occafion requires. CHA Pi Operations of SU RGE RY. 51 I CHAP. LII. Of the Amputation of the Fore-Arm. B EFORE the Surgeon makes the Amputation of the Fore-4rm, he muff, as well as in the Amputation of the other Limbs, get his Apparatus ready, which differs only from the Apparatus of the Leg, according to the different Diameter and Size of the Pieces whereof it confifts. THE Apparatus being ready, the.-Operator places the Patient upon a Chair, and covers his Face with a Napkin, that he may not fee the Operation. And becaufe the firft Circumftance of it is to prevent an Effuiion of Blood, he applies upon the internal and middle Part of the Arm the Cufhion of the Tourniquet; he faftens it with a circular Comprefs, and adapts the Noofe over that Comprefs. THE Surgeon ftanding by the external Part of the Fore-Arm, which he defigns to cut off, bids a Servant hold the Patient's Hand, whilft another holds the upper Part of the Fore-Arm. I fuppofe fome other Servants hold the Patient fo faft, that he cannot ftir. Afterwards,the Operator puts his Hand under the Fore-Arm, to take the crooked Knife from a Servant, with which he makes a circular Incifion, two Inches above the Wrift, applying the Edge of the Knife upon the Radius, as exaaly as he can. IN order to cure the Patient fpeedily, that circular Incifion ought to be made at two feveral times, according to Mr. Petit's Diretion I mean, that 5 A Treatfe of the that the Surgeon muft only cut at firft the Skin and Fat, and raife them to cut afterwards the Mufcles, with a fccond Incifion. IN the next Place, the Surgeon muft have a fmall and very narrow Knife, to pafs between the Bones, turning its Back a little more towards the Part that is to be preferved, for the Reafons above-mentioned. He fcrapes off the Periojieum of the two Bones, &c. To faw the Limb (which is the third Circumfiance) the Operator takes a Saw, with which he Sforms the Line, in which he is to cut upon the Cubitus afterwards he inclines the Saw upon the Radius, and endeavours to end with the Cubitus, or at leaft he makes an End of the Operation by fawing both at once. Now he muft prevent an Effufion of Blood; and therefore he bids the Servant, who holds the Tourniquet, to flacken it by half a Turn; or if the Operator ufes Mr. Petit's Tourniquet, he will do better to flacken it himfelf, as he thinks fit. When the Place of the Arteries is known by the Blood that comes out, they muft be tyed. We have here three Arteries, the radial, the cubital, and that which creeps along the membranous Ligament, that fills up the Space between the two Bones. If thofe Ligatures are too difficult, the Surgeon ufes the Crow-bill'd Forceps, with which he dreffes the Artery, and withdraws it a little to make the Ligature with a crooked Needle threaded with a Fillet, as is ufual or clfe he makes a Surgeon's Knot upon the Crow-bili'd Forceps, and preffes the Artery with that Infirument. Afterwards he makes the Ligature to glide from the Crow-bili'd Forceps, upon the Artery, and compreffes it exatly in that Manner. Opcrations of SUR GER Y 513 THE fame may be done with another Inifrument, called the Valet a 'Patin; nay, the latter is preferable to the former, becaufe it has a Spring, which keeping it faft, will fufficiently comprefs the Artery to make the Ligature. Befides, the Operator who ufes that Inftrument, needs no Servant, fince he may let it hang down, whilft he faftens the Veffel. IF, notwitftanding all the Ligatures, the Blood ihould come out when the Tourniquet is flackened, the Surgeon muff pinch the Veffel with the Valet d Patin, as I have juft now faid, and drive the Needie farther into the Flefh to make a fecond Ligature and if all thofe Precautions are ufelefs, he muft have recourfe to the Button of Vitriol, and the Compreflion together. THOSE different ways of ftopping the Blood fhall be ufed in the Amputations above-defcribed, if there is occafion for them. To drefs the Patient, the Surgeon bends the Stump a little; and then lays upon it the Ligatures made of fmall and thick Compreffes. He covers the two Bones with fmall and dry Plagets. Afterwards he brings the Skin nearer, which, as we have cut it, mufft cover one half of the Stump; and confequently haften its Cure. In the next Place, the Surgeon takes fome Lint, which he applies upon the Stump without any fet Order, and lays over it a round Plaget, and others of irregular Figures. He puts upon that Drefling a Plaifter; in the Shape of a Malta-Crofs, if. he thinks fit, though to fpeak fincerely, it is very ufelefs in the firft Dreffings. He covers that Plaifter with Compreffes of the fame Figure, and lays over theni longitudinal Compreffes, as I have faid, fpeaking of the otherALputations, only with this DiffeL I rcnce; Ar:4A Treatife of the,rencc, that they imuft be very narrow. Lafily, he fupports the whole with the following Ban.v dage. Of the Bandage proper for the Amputation of the Fore-Arm. THE Roller ut'rd for the Amputation of the Fore-Arm, is commonly three Inchies broad, and about thirty Feet long, with one Head. The Sur. gcon applies the End of the Roller obliquely upon the Edge of the Stump, where he makes two circular Turnings, and then he afccnds obliquely to the Elbow. Afterwards he paffes the Roller behind the Elbow, I mean upon the lower and hinder Part of the Humerus; and he proceeds externally along the Fore-Arm, to pafs direfUy upon the Stump. Afterwards he conveys the Globe of the- Rollei along the internal Part of the ForeArm, to pafs agrain behind the lower and hinder Part of the Humerus, and come to the Fold of the Elbow, that he may defeend to the fore-part of the Stump, and crofs with the foregoing Turning. He afc ends again, makincg the Roller to run obliquely towards the external Gondylus of the Humerus, upon the upper of which he palfes, to come internally along the Fore-Arm, and to pafs a third time direCtly over the Stump, taking Care in this laft Circumvolution to cover the Vacuities, which the Crofs leaves upon the Stump; which reprefents a Star, that is very binding. The Surgeon afeends again, to pats behind the Elbow the fixed Point of all the Turnings of the Capeline; and he makes a Circular in the upper Part of the For-Arnm, which itops and faftsi.s the - Turnings Opcrations Of SURGERY*. 515 of the Capeline, and confequently prevents their fliding upon the Olecranon. Lafily, he defcends by Serpentines to the Edge of the Stump, where he makes a Circular, to afcend again obliquely to the lower Part of the Humeras, about which he makes a whole Circular, and ends the Bandage about the Arm. SURGEONs advife to leave as much of the ForeArm as pofliblc, when there is a Neccelity to cut off that Limb. This is good Advice, provided the Mufcles have not been pulled and bruifed, as it happens when a Gun burfts in the Hands, or when the Wrift, the Tendons of the Mufcles, and the Fingers have been, as it were, pulled off by the Splinter of a Bomb, or of a Ship s for in that Cafe 'if the Surgeon will avoid a great Suppuration, he muff cut off the Fore-Arm in the Flefhy Part of the MufCles. Mr. 'Petit having perform'd that Operation, in confequence of a Gun, that burit in the Hands, endeavoured to preferve as much of the Fore-Arm as he could; but his Forefight, commended by all Authors and Surgeons, proved very ufclefs, as he himfelf owns for, not long after the Amputation, the Mufclcs foated in the Pus, which was contained in the Membrane near each Mufcle, and Part thereof being converted into the Mafs of Blood by the Circulation, occafioned a Fever, of which the Patient died. SURGECNs of great Worth and Learning grow wifer by their own Faults; nay, they acquaint the Publick with them, to give occafion to new Reflea ions upon the Parts; and they exhort Praaitioners not to follow blindly the Advices of Authors. L}2 o A, 16 ATreatife of the CHAP. LIII. Of the Amputation ef the Arm. T HE Amputation of the Arm does not differ much from that of the Thigh. However, I fhall give an Account of it, that the Surgeons may know all the different Amputations. To perform that Operation, the Surgeon places the Patient upon an Elbow-chair, covers his Face with a Napkin, that he may not be terrified, and wraps up the Fore-Arm and the Hand with another Napkin. THE Operator having a Cloth before him, like an Apron, as I have faid in the Amputation of the Leg, flands by the external Part of the Arm, and taking the thick Comprefs, or the Cufhion of the Tourniquet, (and fuppofe the Drefling to be ready) applies it upon the external and middle Part of the Arm. He fupports that Comprefs by another, which is circular, or ufes the Tourniquet newly invented. Afterwards he paffes his right Hand under the Patient's Arm, to take the Knife from a Servant, and raifing the Hand, he conveys the Edge of the Infirument, as much as he can, towards the external Part, and lays the Palm of his left Hand upon the Back of the Knife, to ufe the Infirument with more Strength, and cuts circularly the Skin, the Fat, and the Mufcles, two Inches above the Jointure, or elie he makes the Incifion at two feveral times, as I have often recommended. This is the beft PraCtice. THi Operations of SURGERY. 517 THE third general Circumftance of Amputations confifts in cutting the Bone; and therefore the Surgeon draws the Flefh towards the upper Part of the Arm with the fplit Comprefs. Afterwards he fcrapes the Humerus in its Circumference, to take off the ~Periofleum, and faws it as near the fplit Comprefs as he can. To prevent an Effufion of Blood after the Operation, the Arteries muft be tied in the manner abovemention'd. There are generally three in the Arm, which want that Operation, as I have fecn it perform'd by Mr. Petit upon a young Man of twenty Years of Age. The firft Artery that appeared, when the Tourniquet was half flackened, was fituated in the internal Part of the Arm, near the Humerus. The other in the internal Part proceeding from the middle of the Mufcles. Laftly there was a fmall one in the external Part, which ran to the Skin, and was flopped with Lint, upon which the Surgeon laid his Finger. AFTER all thofe Ligatures, the Tourniquet was quite flackened, and Mr. Petit wiped the Stump with fmall Rags; and becaufe the Blood did no longer come out, he dreffed the Patient in the following manner. He applied fmall and thick Compreffes upon all the Arteries; a dry Plaget upon the Bone; and above all that a great deal of Lint, and Plagets of irregular Figures, to make an even Compreflion every where. He covered that Drefling with a Malta Crofs folded double, taking Care to keep one Hand upon the Stump, in order to comprefs the Vefels direly, which ought to be obferved in all Amputations, ABOVE that Malta Crofs the Surgeon applied a fmall fquare Comprefs, dipt in Brandy, AfterL 1 3 wards 418 A Treatife of the wards he laid the long Compreffes, folding into two the End of the firft, to apply it upon the internal Part, that the Vcffels might be ftill compreffed. He croffed the fecond long Comprefs upon the Stump, and the third made a circular Turning upon its Edge. The whole was fupported by the following Bandage. Of the Bandage proper for the Amputation of the Arm. THE Roller, that is ufed to fupport the Drefling in the Amputation of the Arm, is about thirty Feet long, and three Inches broad, with one Head. The Surgeon applies the End of it obliquely upon the external and lower Part of the Stump, (fuppofe the right Arm to be cut) and holding it with the left Hand, he faftens it with two Circulars made upon the Edge of the Stump, to bring together the Coats of the fatty Cells, which are at a great Diftance from one another by a kind of Emphyfema, occafioned by the Impreflion of the Air. Afterwards the Surgeon afcends obliquely to the upper Part of the Arm, and then conveys the Globe to the Acromion, and from thence to the Sternum, and under the left Arm-pit, proceeding obliquely behind the Back, and forming a K upon the right Acromion, to defcend along the forepart of the Arm. Afterwards he paffes diredly upon the Stump, conveying the Globe of the Roller, firft along the hinder Part of the Arm, and then along the external Part, to pafs a fecond time upon the Acromion, upon the Sternum, unicr the left Arm-pit, obliquely behind the Back, and form a fccond K upon the Acromion, taking Care Operations OfSURGERY. 4519 Care that it be above the firift. Afterwards he muft defcend along the internal Part of the Arm, to pafs a fecond time direUly over the Stump, taking Care to crofs with the foregoing Turning; and then he afcends along the external Part of the Arm, to pafs a third time upon the Acromion, upon the Sternum, under- the left Arm-pit, obliquely behind the Back, and make a third K above the two firft upon the Acromion. He brings down again the Roller along the Arm, to pafs a third Time over the Stump, taking Care to cover the Vacuities, which the other Turningshave left, which forms a Star of great ufe in all the Cepelines, as I have faid above, not to mention the Beauty of the Bandagc, The Surgeon conveys a fecond time the Roller along the Arm, to pafs upon the Acromion, upon the Sternum, under the left Armpit, obliquely behind the Back, and to come upon the right Acromion, in order to cover tihe Ks that have been made on it. Laffly, he conveys the Globe by Serpentines downwards about the Arm; and being come to the Edge of the Stump, he makes a Circular, and then he afcends obliquely to the Acromion, and ends the Bandage about the Body. AFTER the Operation, the Patient is laid down, and the Stump muff be fupported by a Cufhion, It muff alfo be covered with a Sheep's Skin, or fomething elfe, which ought to be warmed now and then, in order to keep up the Heat i/thlat Part. THE Cure of Amputations confifis in blooding the Patient, if his Puilfe rifes never fo little; in giving him a Clyfter now and then, and nourithing him only with Broth, every three Hours, Night and Day, and fometimes with a Spoonful of Jelly. L I 4 Tos 5o A Treatife of the THOSE different Amputations muft be drefled only four and twenty Hours after,. at the foonefti and in the firft Drefling the Surgeon muff only take off the Roller and the long Compreffes, and then imbibe the remaining Part of the Drefling with warm Brandy. On the third Day, the Plagets do generally flick flill, and therefore they are imbibed again with, the fame Remedy, and the Drefling is laid on again. Laffly, on the fourth or fifth Day, the Plagets fall off themfelves; and then the Surgeon muft drefs with Lint-plagets covered with a Digeftive, and take Care not to remove the Compreffes from the Arteries, 'till they fall. IN that gentle and eafy Method of dreffing Amw putations, the Surgeon fees, on the fourth or fifth Day, a fine Suppuration of well digefted Matter, and not too plentiful. And when he has ufed Affringents, which contral& the cut Extremities of the flefhy Fibres, and the fmall Capillary Veflels, there happen in thofe Parts fmall Phlogofes, which inflame the whole Stump, and retard the Suppuration very much; and when it comes to a Head, it grows fo plentiful, upon the Phlogofes being refolved, that there happens a confiderable Lofs of Subftance, as I have moft times obferved in the Hofpitals. SINCE the Air contra6ts the Extremities of the fame Veflels to fuch a Degree, and coagulates the nutritious Juices contained in them, in fuch a manner, that it frequently occafions a Reflux of Mlatter, which makes the Wound dry, or too plentiful a Suppuration, whereby a great deal of Subftance is loft; it cannot be denied, that the Impreffion of the Air is very pernicious, and confcquently Ofcrations of SURGERY. 52I kIquently that frequent Drcflings are dangerous: If the Patients are dreffed twice a Day in Hofpitals, 'tis becaufe Aftringents have been ufed, which occation afterwards Suppurations fo plentiful, and very often fo ferous, 'that 'tis neceffary they fhould be dreffed frequently; befides, the grofs and corrupt Air, that prevails in thofe Places, requires it; But that Method ought not to be exafly obferved elfewhere; and the Surgeon muff drefs feldom, and as quick as poflible. CHAP. LIV. Of the Amputation of the Arm in the Joint. T HE Arm ought to be cut off in its Articulation with the Shoulder Blade, for two plain Reafons; the firft is a Fra&ure of the upper Part of the Humerus, occafioned by the burlting of a Bomb, the Fall of a Houfe, and a Thoufand Caufes of that Nature: The fecond is the Defe& of the Joint itfelf fuch as the fwelling of the Head of the Humerus or a Defe& in the Articulation, fuch as an Abfcefs, &c. THIS is a very difficult and long Operation; and therefore to remove thofe Difficulties, a Surgeon muft never undertake it, without the Advice of Phyficians, and other experienced Surgeons. BE FORE he proceeds to that Operation, his Drefling muff be ready, as well as in moft other Operations, He places the Patient upon a Chair, and in a convenient Place, he covers his Face with a Napkin folded in two, that he may not fee the Operation. That Operation is very different from other Amputations, becaufe no Tourniquet is ufed to ftop the Blood, and the Ligature is made in the Veffels before the Flefh is cut, To 52 A Treatife of the To prevent an Effufion of Blood after the Operation, I fhall fet down the Method of Mr. Petit, a Man of a vaft Genius, and a great Surgeon. In the firft Place, he raifes the Patient's Arm, which makes a right Angle with the Body. THE Arm being thus raifed, the Surgeon perceives the Veffels that run into the Arm-pit; but if the Diftenfion is fo great, that he cannot perceive them, he muff make lateral Incifions. AFTERWARDS he takes a crooked and large Needle, fharp on both Sides, and threaded with a Fillet, confifting of fix or eight Threads; he conveys the Point of the Needle on the Side of the Armpit, and two Inches from it s he drives it in, 'till he finds the Neck of the Humerus, which he fcrapes, if I may fo fay, with the Point of the Needle, and brings out the Point of the Needle on the other Side of the Arm-pit. WHEN I fay that he fcrapes the Bone with the Point of the Needle, I mean, that he muft pierce the Flefh by paffing the Needle as near the Bone as poflible; but the Bone ought not to be grated for that Operation would be extremely painful, and the Point of the Needle being blunted, by ftriking againft the Bone, would be no longer able to make an End of the Operation: Befides, if the Ligature was fo near the Bone, the Surgeon would run the Hazard of cutting it, by fcparating the Bone from the Flefh, as I fhall fay hereafter. And if the Ligature was too far from the Bone, he would run the Risk of paffing the Needle through the Veffels, opening them, and occaftoning a great Diforder; from whence it appears, that'tis very proper to keep a Medium. THE Operations of SURGERY. 523 THE Needle being driven, as I have juft now faid, the Operator lets down the Patient's Arm to loofen the Skin afterwards he makes a Surgeon's Knot with the Thread, which he tyes very tight, and affoon as he has made that Knot, he fees whether the Blood be ftopped, by feeling the Artery three or four Inches under the Ligature; and, if he feels no Beating, he makes a fecond Knot above the firit, and faftens the two Ends of the Fillet with a Loop. WHEN he has thus flopped the Stream of the Blood, which ran into the whole Arm, he mufft preferve a great deal of the Skin, cut the Flefh, and extirpate the Arm. In order to do thofe three Things, M, Petit takes Notice of three Circumftances the firft is to fecure the Acromion the fecond, to draw the Skin; and the third, to make the Incifion, two or three Inches under the Acromion, in order to leave a greater Quantity of the 'Deltoid, and to fill up the Vacuity after the Operation, and by that Means to cure the Patient more fpeedily. AFTER thofe Obfervations, the Operator ufes a firait Bifjouri, to cut tranfverfly the Skin, the Fat, and the 'Deltoid, in the Place above - mentioned; afterwards he gives a fmall Motion to the Arm, by raifing it a little, and perceives the two Heads of the Mufcle Biceps, which muft be cut off with the fame Inftrument. And if during thefe Incifions fome Arteries fhould emit a great deal of Blood, the Surgeon mufft flop it immediately, by applying a heap of Lint, kept on clofe by a Servant. During that Time, the Operator fhall cut the circular Membrane which furrounds the Jointure, and will unbridle on both Sides, as much as may be. Afterwards he conveys the Fingers of his left Hand to the upper Part pf the Head of the Humerus, and draws it a little. There p 4. A Treatife of the There with the Bifouri he unbridles and cuts the Sides that are cumberfome, and by that Means he is at Liberty to fee, whether the Ligature of the Veffels be well made. In the next Place, the Surgeon muft preferve the Skin, and the Mufcles that are tyed with the Veffels 3 and therefore he cuts thofe Mufcles longitudinally on each Side, and leaves a Shred of a triangular Figure, the Bafis whereof lies towards the Arm-pit, and the Top remains blunt, fquare, and of a Figure adapted to the remaining Part of the ~Deltoid fo that after fuch an Operation, the Limb has no hold left. SOME advife to make a circular Incifion. I think the Method I have propofed is preferable, becaufe when the Operator makes the Incifion circularly, he runs a great Hazard of cutting the Ligature. But fuppofe that Accident fhould not happen, there would be a great Lofs of Subftance, which could not be cured but in a very long Time, and might occafion fome Diforder; whereas, if we follow Mr. Petit's Method, there will remain two large Pieces, which may foon be reunited, and which might be futured, when the Ligatures fall off. THAT Amputation being made, the Surgeon muff examine the Veffels adhering to the remaining Piece, and pafs under them a Needle threaded with a Fillet, without the Skin. He ought to make that Ligature one Inch above the firft, and make it tight, becaufe it muft flop the Blood. Afterwards he cuts the firft Ligature, becaufe it preffes upon the Skin, and there might happen an Eryftpelas, attended with fad Accidents, and even with Death. To drefs the Patient, the Surgeon lays a Plaget upon the Stump, and a Comprefs upon the Arterigs, to prefcrve the Ligature. Afterwards he raifes the Operations of SUR GER. 5 2 the remaining Piece of Flefh, and brings down that which remains of the Skin and the 'Deltoid Mufclc; he fills up the Whole with dry Plagets and Heaps of Lint; and covers that Drefling with a Plaiffer made in the Form of a Malta Crofs. Above that Plaifter he lays a fquare and thick Comprefs; he puts a round Comprefs into the Arm-pit to comprefs the Veffels, that they may not drive the Blood with fo much Impetuofity; He covers the Whole with a Comprefslike a Malta Crofs, folded double. Above that Comprefs, he applies two large longitudinal Compreffes, four Inches broad, and two third Parts of an Ell long; he applies the middle of the firit obliquely upon the Dreffing, and the foremoft End comes over the oppofite Shoulder, and the hinder End reaches four or five Inches under the found Arm-pit:The fecond longitudinalComprefs mulf alfo be applied obliquely upon the Stump, in fuch Manner, as to be croffed by the firft. Laftly, he applies a third of the fame Length, and fomewhat broader, which covers the two firft, and lies crofs upon the oppofite Shoulder., That Dreffing is fupported by the following Bandage, called The defcending Spica. But before the Surgeon makes that Bandage, it is not improper to lay a finall Cuthion under the oppolite Arm-pit, that the Turnings of the Roller may not comprefi the Veffels, and that it may the more commodioufly ferve for the Bandage. Of the Defcending Spica properfor the Amputation of the Arm in the Joint. THE Surgeon ufes for the 2Defcending Spica a Roller with one Head, four Inches broad, and fix and thirty Feet long: He applies the End of the Roller 516 A Treatife of the Roller before the Breaft, near the right Arm-pit; becaufe I fuppofe the left Arm is to be cut off. He bids a Servant hold that End of the Roller in that Place, and conveys the Globe tranfverfly upon the Drefling; and then, pafling behind the Back, he comes under the right Arm-pit, to make an End of the Circular: He makes the fame Turning a fecond Time s and when he is under the right Armpit,he afcends upon the Acromion, on the fame Side i he conveys the Roller behind the Back, obliquely upon the Dreffing, and comes under the right Armpit, pafling over the Sternum; he afcends the Acromion, and comes before, to pafs obliquely over the Dreffing, and confequently to crofs with the firft oblique Turning, in order to form the firft Folds of the Spica: He goes on with the fame Circumvolutions, 'till the defcending Spica be ended; and then, with the remaining Part of the Roller, he makes Circulars, which pafs horizontally over the Drefing. THE Patient is blooded two Hours after, and that excellent Remedy is repeated as often as is neceffary. He is only nourifhed with Broth, and fometimes with a Spoonful of Jelly. THAT new Operation was performed fome Yeats ago, with good Succefs, upon the Marquis de Coetmadeu, by Mr. Le iDran, affifted by the prudent Advices of Mefieurs Marefchal, Lapeyronie, Arnaud, and Petit. The END of the OPERATIONS. A SHORt 5j17 A SHO RT DESCRIPTION OF THE INSTRUMENTS That are Ufed in Chyrurgical Operations. U R G E R Y is an Art of aval Extent; and yet it contains nothing that is S ufelefs: The very Initruments that are ufed in Chyrurgical Operations, ought to be tkoroughly known. Surgeons do not take a fuificient Care to perfct them; they are hardly able to judge of their good or bad Conftruaion, (efpecially in the Country) or of the Ufefulnefs and Inconveniencies they may be attended with in the Pratice. That Ignorance is frequently the Caufe of great Faults; and many Operations have not a good Succefs, becaufe the Inftruments made Ufe of are defedive: Nay, it happens fometimes, that Patients are not relieved, for Want of nccff1r and good Inftruents FEW 18;A Short Defcription FEW Authors have treated that Subje&. Guil. lemeau and Scultet, who enlarged upon it more than others, have done it fo immethodically, that far from inftruding us, their Books have brought into Contempt, among many Surgeons, thofe who invent new Inftruments, or endeavour to perfed the old. I fhould therefore be guilty of Rafhnefs in believing that I can difcourfe of them better than the ancient Praftitioners, were I not dire&ed in this Matter by thofe excellent Maftets, whofe Advices I have followed in the whole Courfe of the Operations, which I have defcribed. I am indebted to Mr. Arnaud for the Order I fhall obferve in this Treatife. He is the firft, who has demonftrated Chirurgical Inftruments publickly; he has fet them in their beft Light, and cleared that Subje&, which had been handled before with great Confulion. I fhall add to the Method and Difcoveries of that great Surgeon, fome Inftruments of Mr. fPetit, and Mr. Lapeyronie, and what my fmall Abilities afford me upon this Matter, together with the different Terms of the Parts of each Inftrument, which I have learned of the beft Artifts, and particularly of the Sieur Vigneron, who excells in his Profeflion, and marks his Work with an Ace of Clubs. We have two forts of Chirurgical Inftruments, fome are Natural, and others Artificial. The natural Infiruments of a Surgeon are his Hands, which ought to, be neat and clean, rather long than fhort, fceady, and both of them equally dexterous. Befides, the Joint of his Wrift ought to be lteady, and the Phalanges of his Fingers pliant, and of a good Conformation. The Skin of the Fingers end, efpecially of Chirurgical inffrunaents. 5129 efpecilly of the fore and middle Fingers, ought to be fine and nice for the Feeling. When a Surgeon can do without Artificial Infiruments, the natural ones are preferablec, becaule they anfwver his Intention more fpeedily and fafely, and without any trouble. The Surgeon's Hands muff alfo be diredted by a good Sight. ARTIFICIAL InflArumnCts are uifed by a Surgeon, when his Hands are not filifcient. They confift of diffcrent matters; -but generally of Iron and Steel, foine are made of Gold, Silver, Lead, and other Matters. It is abfolutcly necefllary that fomre Infiruments f ould be nmadie of Iron and Steel, -or both together, fuch as thoti', which ought to malke a great Relifiance, or cut with their Edges, &c. Others require to be made of Silver fihch are pliant Infiruments, the Catheters, the Cannu1/ias, and fome Siphons very finall, &c. But many others may be made indifferently of Iron, Steel or Silver; and this laft Metal is frequently preferred to others only for the fake of Neatnefs. To give a particular Defcription of each Inflrument, I fhall reduce them all to three Claffies. The firft contains thofc, that are uLfed to prepare the Drefling; the fecond, thofe which ought to be made ufe of to drefs Wounds; the third, thofe that are ufeful in the feveral Operations of Surgery, or peculiar to them. The Infiruments of the firft Clafs are but fcwv viz. a Needle, Thread, Sciflirs, and a Spatulda. To give a juff Notion of each particular In' firument, I Ihould begin with a Definition; which is no eafy thing, fince no Body has done it hitherto. Befides, there are fome Infiruments, which not being capable of a true Definition, canx m nnot 530 A4 Short Defcription not be well explained without a large Defription; and others are l0 well knovwn, that a Definition, or a Dcfcription, would only darken the clear Notion we have of thcm: However, I fhall endeavour, as much as I can, to give at firfit an Idea of each Infirument, and then confider all its Parts, and its feveral Ufes. THE Needle in general is a fmall Rod of Steel, or fome othcr Mcetal, pointed at one End, and bored through at the other, to pafs into it fome Thread, Silk, or fome other Tyc; and it is ufed for fowing, embroiderinr, &c. I ihall hereafter give a more particular Account of Needles; for this is not a proper Place to mention thofc that are made Ufe of in Operations. THiE ufual Needle ferves in the Dreings to fow together the Ends of Rollers, and the Folds of Compreffes, and to join feveral Pieces of Linnen, in order to make compounded Bandages. THE T rTead is a Coll1ction of long and thin FiIamcnts, taken from the Bark of Hemp, Flax, &rc. twifred between the Fingers with a Spindle, or with the Help of a Spinning-Wheel. There are feveral Sorts of Thread, as I have fhewed, difcourfing of Sutures;3 but that which we ufe to prepare Dreffings is made of Hemp: It is commonly called Bretagne Thread, and known in this Province by the Name of TwiýJed-Th-read. Sci/[ars are an Inftrument of Steel and Iron, confifting of two cutting Branches, which are joined together by a Nail: Some compare ScJfors to two Knives applied upon one another, to cut whatever happens to be within the Space of their Edges. The cutting Part reprefents the Blade of the Knife, and the other Part the Handle; but thofc two Parts joined of Chirurgical Inftruments. 5 joined together are looked upon by Artifts as a Branch; as I have faid in the Definition; and becaufe there are two Branches in Scifars, the one will be the upper, and the other the lower. I call the upper Branch that which lies under the Cloth when it is cut, and the Ring whereof muft be held by the Ring-Finger. On the contrary, the lower is that, the End of which, either buttoned or blunt, as I am going to fhew, muff be upon the Cloth, and the Ring whereof is held by the Thumb. THE hinder End of each Branch confifts of a Ring, which ought to be fomewhat long, to adapt itielf to the Figure of the Fingers, and flat in its whole Circumference, that having a larger Surface, the Fingers may a& upon it with more Strength. Surgeons muft take Care to get the Rings of their Sciffars made fuitable to their Fingers j for Workmen generally make them much of the fame Size, and therefore fome Fingers being very large, can hardly get into the Rings, which is no fmall Conftraint in the Operation; and others are fo fmall, that the Rings moving to and fro about the Fingers, render the Afion of that Inftrument unfafe. THE Part next the Ring is what I call the Handle; its Figure reprefents an irregular Cylinder; it may be of Silver, as well as the Ring in thofe Sciffars, that are defigned for the Dreffing, but in thofe that are to be ufed for an Operation, the whole Branch muft be of Steel. THE Handle ends with an Hexagon Figure, exa&ly Symmetrical from one Branch to the other: Workmen call it the Shoulder. They contrive in the internal Part of that Shoulder in each Branch, a confiderable Depreflion, which joining with the Mm z other 532 A Short Defcription other Branch, does not form a Bulk more raifed than the Handle: Workmen call that Jundion. THE Nail, which is the fixed Part of the Sciffars, and keeps the two Branches againft one another, ought to be fixed upon one of the Branches, that it may fupport the other to move more regularly to, that End, one of the Branches muff have a fmiallr Hole, or the Nail muff be larger in that Place: If this Mcchanifmi was not obferved, and the two Branches ihould waver alike upon the Nail, the Motion of the Sciflhrs would be irregular, and confequently their Adion more unfafe. WHAT follows from the Shoulder to the foremoft End of the Sciflars, is called the Blades, as I have already faid they muff be flat in the Infide, and convex on the Outfide, that the whole Strength may tend to the Infide: The two Blades of the Sciffars mufft not be very far from one another, becaufc they would not cut what happens to be between tecir Edges; they muft be neither too clofe, nor, as it were, crooked in the Infide; for the Edges would get upon one another, and notch one another. Lafily, the Blades of the Sciffars, defigned for Drcflings, end differently, viz. the upper Blade with a very fharp Point, and the lower with a blunt Point, or a Button, to flide under the Cloth, that is to be cut, and to prevent piercing it, which would happen with a fharp Point. I look upon Sciffars as a kind of Lever, the Power whereof is in the Rings, the fixed Point in the Nail, and the Weight in the Edge of that Inftrument; fo that the farther the Power is from the fixed Point, the fironger will the Infirument be. THE Ufe of Sciffars, proper for Dreflings, is to cut the Threads, the Fillets, the Plaifters, the Comprcflcs of Chirurgical lnftruments. 533 preffes, the Cloth, and whatever is more than is wanted; but to make a good Ufie of them, the Surgeon muft put his Thumb into the lower Branch, and the Ring-Finger into that of the upper Branch, for fome Mechanical Rcafons, too long to be here inferted. Afterwards, if the Surrgeon cuts, for Inftance, fobme Linncn, he puts the blunt, or buttoned Branch underneath; he lets down the VWrift a little to. raifie that buttoned Branch, that it may take in the Linnen in its whole Extent; and then. he cuts the whole Linnen with the Sciltars all at once. THE Spatula is a finall Infirument, fomcwhat long, flatted, and round at one of its Ends, to fpread Unguents. THE Spatulas may be of Iron or Silver; the latter are neater, and the former firongecr. Spatulas in general are of different Figures; but the moft regular are like a finall Lever, one End whereof is flat, and round at the End, and the remaining Part of that Inftrumcnt lefl-ens more and more, as far as the other End, which is fomewhat crooked, and provided with fmall tranvcrfal Grooves, like an Elevatory. THE Ufe of the flat and round End, whereby the Spatula is diftinguithed from other Infiruments, confifts in fpreading the Plaitters upon Linnen, or Leather, and the Unguents upon the Plagets, and fometimes upon the affctcd Part; but the oppofite End ferves to raife Pieces of Bones difplaced, or fradtured, in any Part whatfoever. THE Ilftruments of the fecond Clafs, for the Drefling of Wounds, are of two Sorts: Some are proper to drefs the Outfide of Wounds, and others arc ufed to drefs the Infide. Thofe of the firi Kind Mm 3 arc 534 AShort o Defcription are not many. We reckon among thofe Infiruments the Myrtle-Leaf and the Razor. THE Myrtle-Leaf is a fmall Infirument, pretty like the Spatula, only with this Difference, that the Myrtle-Leafis narrower, and ends with a Point. That Inftrument has been fo called, becaufe it is fomewhat like the Leafofa Myrtle-Tree. There are feveral Kinds of it, by reafon of thofe Things that are added to its other End; for Surgeons add to it fometimes a Pincer, which fcrves to drefs Wounds, and to diffet&; fometimes a Spoon to take a Ball out of a Wound; and fometimes a finall flat and round Button, called Meningophylax, which is ufed to prefs upon the )Dura Mater. THE Myrtle-Leafferves to clean the Edges of a Wound, and to remove the Filth gathered therein by Plaifters, or by the Pus coming out of the Wound. Some Surgeons ufe that Infirument, as if it was a Spatula; but far from approving of that Method, I am very much againft it; for a Surgeon, who ought always to drefs a Wound as neatly as he can, muft not take Unguents, and fpread them upon Plagets, and even in the Wound, with an Inftrument defigned to remove the Filth out of it. T HE Razor is fo well known, that I need not defcribe it; I fhall only give an Account of the Ufefulnefs of that Infirument in the Dreflings; it is ufed to fhave the Hair growing about a Wound, and even to take off the Filth which the MyrtleLeaf could not remove, and to uncover by that means, the Pores of the Skin, in order to promote its Tranfpiration, and preferve it from the acrimonious Impreffions which that Naftinefs might occafion. This is of no fmall ufe for the cure of a Wound. The Razor is alfo ufed to fhave the lHair oJ Chirurgical Inflruments. 5 35 Hair of thofe Parts, upon which emplaftick Remedics are to be applied, that the Patient may not fuffer any Pain, as he would when the Hair is plucked out by taking off thofe Remcdics. YoungSurgeons muff not neglecT the Ufe of the Razor, for it will very much contribute to make their Hands more pliant and nimble. LAS T L Y, The Infirumcnts of the fccond Kind, which ferve to drefs the Infi~d of a Wound, are in greater Number, and the Probe is the mofi confiderable. BY the Word 'Probe, we mean a finall Rod of Iron, Steel, or Silver, blunt, or with a Button at the end of it, to prcvcnt hurting the Patients, and which is introduced into a WVound to know its Depth, and thofe Parts that are affecdcd. A M O N G thofeProbes that ferve to difcover the Depth, the Meanders or different Complications of a Wound, the Silver Stilets are the moff convenient, efpecially when they are nealed, becaufe the Surgeon may bend them, and give them fiich a Figure as is requifite for the different Windings of the Sinuofities of Wounds or Fifiulas. It is uflual to add to one of the ends of certain Iron Probes, or Silver Stilets, an opening fomcwhat long, and like that of Needles, wherein there are two finall Grooves, one on each Side of the Opening, to pafs a Seton through the Wounds, or to ferve for fome other Operation. The fecond Infirumcnts proper for drefling the Infide of Wounds, are the Forceps. 'Tis a finall Infirument of Iron, or Silver, confifting of two Branches, which is ufed to take or place fbme Things which could not be taken or placed io eafily with the Fingers. Thofe two Branches are diffcrently M m 4 fhaped 536 A Short Defcription ihaped in the middle 3 one of rhem is flat, and made thin, the other is wider and flit. The firft enters into the Slit of the fccond, and is therefore called the Male-Branch by Workmen; and the fecond Branch goes by the Name of Female, by reafon of its Slit. The Union of thofe two Branches is called an Infide Joint. ForccpsPs in ogeneral, are different in Size and Figure; but thofe that are commonly ufed to put fome Parts of the Drefling into the Wounds, are of two SCorts. The firft is a double Forceps, the Ends whereof are kept afunder by the help of a Spring. Thoe feForceps's, as well as thofie that are clapped upon the end of fome Myrtle-Leaves, can hardly be of ulfe but in fuperficial Wounds. T I E fecond Sort of Forceps, confifts of two Branches, as well as the firit; but it differs from it, becaufe in its hinder Part there are two Rinus, like thofe of Sciffirs. Thofe Pincers are preferred to all others, not only becaufe they are ablolutely neccflary to drefs deep Wounds, but alho, becaufe they are more able to take out extraneous Bodies, and may alfo be of ufe in fuperficial Wounds. AL L the Forceps that are ufed in Surgery, muff have in the infide fome Unequalities, Cavities, or Slits at the foremoft End of their Branches, as I ihall fay hereafter; but their Unequalities are different, according to their feveral Ufes. For Inflance, thofe Pincers that muft convey fome thing into a Wound, and take it out, muft have oblique Unequalities, croffing one another, like thofe of Files; it is alfo ufLual to make them tranfverfal and parallel. Thofe which are delign'd to comprefs fome Parts of the Body, fuch as the Forceps, which ferve in the Suture of the Tendon, have longitudinal Unequalities; of Chirurgical Inftruments. 5 7 ties; and thofe that ferve to take out fome extranc. ousBodies, muft alfo have different Unequalities, according to the kind of the extraneous Body. i TH E third Infirument made ufe of for the drwcf fing of the Iniide of Wounds, is the Syringe. By that Word we mean a round and long Veffel; and confequently of a cylindrical Figure, which ferves to pump Liquors, and to convey them into deep IPiaces, whitihcr they cannot come but by this Me ans. TH E Syringe confifis of three Parts, viz. Its Body, its Sucker, and its Siphon. The Body of the Syringe is a hollow Cylinder, which muft have a' futficient Diameter; for, if that Cylinder was very long, two Hands would be necelary to drive the Liquor into the Wound, fince the Ring of the Sucker would be too far from the Body of the Syringe, which is commonly held with the fore and middle Fingers, the Thumb being in the Ring of the Sucker 3 the Breadth of the Syringe is alfo of ufe to contain more Liquor. Laftly, That Cylinder mutt be very fmooth in the infide, that the Sucker may flide more eafily; but it muft have in the outfide fome Unequalities, like fmall Circles, to hold it more fteadily. THE Sucker of the Syringe is a kind of Handle, confifting of the fame Matter as the Cylinder, and its Ends are different. The foremoft End, or that whichgoes into the Cylinder, confifts of two round Circles, which are at a greater or leffer Diftance from one another, according to the different Length of the Syringe. The Space contained between thofe two round Circles, is filled up with Hemp, which ferves as Felt, to fill up the Vacuity exatly,- and to pump and drive the Liquor more perfetly. Tht -hinder 538 A Short De pription hinder End, or that which muft remain out of the Cylinder, is of different Figures. Some put to it a Button, others a Ring: The Ring is more proper, becaufe the Thumb being in it, it cannot move to and fro, as it happens when the Thumb is upon the Button. THE third Part of the Syringe is the Siphon. It is a fmall Tube, the Bafis whereof is broad enough, and it ends by Degrees with a Point, being like a Pyramid; that Tube is frequently fodered upon the Middle of the foremoft End of the Cylinder, and fometimes it is fcrewed upou it. Thefe Tubes are effential to a Syringe; they muft be of different Figures and Sizes, according to the different Parts,' and different Difeafes. But befides thofe Sorts of Siphons, a Surgeon muff have feveral other Kinds of them; and thefe are called auxiliary Siphons, becaufe they are added to the effential ones, in order to convey the Remedies into deep and winding Ulcers, and to pump out the purulent Matters and Injetions, it being certain that fuch Abfceffes and Impoftumations cannot be cured, unlefs the Remedy be conveyed into the very Seat of the Difeafe, and the End of the Siphon lie within the Matters, to pump them out more eafily and exafly. It appears by this Defcription, that thofe auxiliary Siphons muft be of different Sizes, according to the Length of the Sinus's, and that they muff have different Figures, according to the different Windings of thofe Sinuofities. It is therefore abfolutely neceffary that they fhould be fo made as to refift and yield to all thofe Figures, like Silver nealed: Their End, which ought to be adapted to the effential Tubes, muft be fomcwhat broader, and of Chirurgical Inftruments. 939 and like a Funnel, to contain exafly the pyramidal End of the Siphon, or effential Tube of thý Syringe, and the oppofite Extremity fhall be open by Orifices in the Sides, that the Surgeon may unftop thofe Siphons, by introducing a finall Stilet into them. T HE fourth Inftruments that are ufed in drefming the Infide of Wounds, are the Cannulas. B Y that Word we mean a fmall Tube of Goldi Silver, Pewter, or Lead, which is put into a Wound, to keep it open, and facilitate the Iflhe of itagnanating Matters. Cannulas in general, are of difftrent Kinds and Figures, according to the Places wherein they are ufed: For Inftance, that which is ufed in the Operation of the Bronchotomy, is, as I have faid, very fmall and flat: Thofe that are introduced into the Bladder after the Extraftion of the Stone, or the Pundion in the RPerineum, are folid or pliant, of a cylindrical Figure, and about four Inches long, having at their Head two fmn&ll Handle-loops, into which they pafs a String to keep them fteady in the Wound. The Cantsla made ufe of after the Operation of the Empyema, is commonly two Inches long, more or lefs broad, according to the Size of the Orifice, flatted to adapt it felf to the Interval of the Ribs, and crooked to avoid the Lungs. I have fhewed the Ufelefnefs and Difadvantage of this laft Cannula, difi courfing of the Empyema. If the Camutas, in general are too long, Surgeons don't advife to cut them in order to make them fhorter, but to ufc a fmall Linnen Conprefs, more or lefs thick> according to the Length of the Cannula, and to pierce that Comprefs in the middle, in order tolet into it the Cannula, which will reft upon it. I have 540 A Short Defcription I have placed under the third Clafs of Infiruments, all thofe that are ufed in Chirurgical Operations: Moftiof thofe Inftruments ferve to make Divifions, and are reduced to two Claffe s; the firif contains thofe that are made ufe of in the Operations proper for the foft Parts, and thofe that ferve in the Operations upon the hard Parts. THE Divifions we are obliged to make with thofe Infiruments, are generally attended with great Pains; and thePatients being afraid of thofe Pains, do frequently lay afide the Operation, and give up themfelves to a medicamental Surgery, the Succefs whereof is very uncertain. We fee every Day a confiAerable number of Patients, who trufling Quacks, or timorous Surgeons, little acquainted with. Anatomy, and unable to make any Obfervation upon particular Cafes that occur in Surgery, live a lingring Life, and continue under their Illnefs. On the contrary, a good Surgeon is fully,perfwadcd by his Skill in Anatomy, by his own Experience, and that of the great Maftlers, that of all Remedies, the Operation, and confequently the Inflrument, is the moft fpecdy and the fafeft. SINCE we reap fo many Benefits from thofe Inftrunients which are ufed in the Operations of Surgery, I ihall give as exa& a Decfcription of them as I can; and becaufe I have faid, that thofe Infiruments divide the foft Parts, or the hard ones, I fhall fitft difcourfe of the former, and then give a Defcription of the latter. THE Inftruments of the firft Kind are of two Sorts: Some are applied upon the dead, and others upon the living; the former are ufed in Diffeaions, fnich as the Scalpels, and many others, which Anatomifts make ufe of. THE of Chirurgical Inftruments. 5$4 THE Inftruments of the fecond Kind are placed under two Claffes: The firft Clafs contains thofe that are ufed in moft Operations; and the fecond, thofe that are peculiar to each Operation, asI thall fhew hereafter. THE Inftruments ufecd in all Operations, are Probes, Biflouris, Lancets, Sciffiars, and many others, which I fhall name in their proper Places. Among Probes, fome are round, and have a Button at the end, as I have thewed before, and others are grooved in their whole Length; and a Surgeon ought to have two Sorts of thefe laft Probes, fome flopped at the end, which muff get into the Wound, and the others open, to be adapted to. the different Incifions which the Surgeon is oblig'd to make: For when he can introduce the grooved Probe into a* Wound or a Sinus, he muft generally,ufe thofe that are flopped at the end; I fay, genSrally, becaufe he is fometimes obliged to make Incifions, wherein the cutting Infirument mufft be higher than the Groove of the Probe, and then the Probemuft be open at the end, that the cutting Infitrument may not be flopped in it. But there are frequently Sinus's, of which the external Orifice is fo narrow, that a fmall Stilet can hardly get into them. In fuch Cafes, the Probe grooved -and open at the end is of great Ufe, as I have Ihewed by one Inftanee, difcourfing of the Fifula in Ana. THE Bifouri is a kind of tharp Razor, that is ufed by Surgeons to make Incifions. I fhall fpeak of the two Parts of that Inflrument, viz. the Blade and the Scale. The Blade of the Bifouri muft not be above four Inches long, and five or fix Lines broad towards its Tongue, which is pierced to let a Nail into it, that goes through 5.i A Short Defcription through the two Blades of the Scale, and is rivctted on both Sides upon two fmall Eyes. In the hinder Part of the Tongue of the Biflouri, there is a Tail, ending with a fmall Button, to faften the Blade upon its Scale; that Blade leffens by degrees from its Tongue to its fore-part, fo that in fome Bifouris it ends with a very fharp Point, and in others with a blunt one. All Bifouris have their Back rounded, a Bevil on both Sides of the Back, and then a confiderable Hollow on both Sides of the Blade, to end with a very fine Edge. A Surgeon muft have fome Biftouris firait, and others crooked, for when they are too crooked, they ate inconvenient. Laftly, A Surgeon muft have fharp and blunt Biftouris of both Kinds. THE Scale confifts of two fcaly Lamina, much like the Figure of the Blade; they are joined together at their Ends with riveted Nails. TH E Ufe of the Bifouri is to make Incifions in moft Parts. B Y the Word Lancet, we mean a Chirurgical Inftrument, very fharp at the fartheft end from the Scale, and cutting on the Sides of its Point, ferving to open Veins, Arteries, Abfceffes, &c. T HE Lancet confifts of two Parts, a Blade, and a Scale or Handle. The Blade is pretty like the Figure of a Pyramid, the Point whereof is very acute 3 that Point muff be very fmooth to an Inch of its Body; and the two Sides of that fmooth Part muff be very fharp. The whole Bafs and Middle of the Blade, are generally neither fmooth nor fharp on the Sides, that the Surgeon may keep the Lancet more fceadily, and not run the hazard of cutting his Fingers, as he would do if it was fmooth every where, fincc it might -lide, and the Edges would hurt him. THOSE of Chirurgical Inftrumnents. 543 T Ho s0 S Blades in general are of different Sizes and Breadths. There are four Sorts of Lancets; the firft is called a full pointed Lancet, its Blade begins to lofe its Breadth only very near the Point, and therefore it is very broad, and can make a large Opening, by driving the Lancet into the Veffell; and therefore a Surgeon ought to prefer it to the others as much as poffible, efpecially in fuperficial and large Vefelts, for which it is always proper. The fecond Kind is called a Spear-pointed Lancet, that is, its Point is longer than that of the firft, and generally begins about the middle of the Iron; this fort of Lancet is proper for thofc Veffels that are of fome Depth. The third Kind is called a Pyramidal Lancet; this begins to lofe its Breadth at its. Bafis, I mean near the Nail, fo that leffening by degrees, it ends with a very long and tharp Point, like a true Pyramid. Such Lancets mufft never be ufed by Prentices, becaufe they are only proper for the deepeft VeIels, and unlefs a Man has a ficady Hand, and knows how to ufe them, he may do much Mifchicf. ALL the different Kinds of Lancets juft now mentioned, may be of ufe to open Abfceffes, when they are fuperficial, and confequently there are but few Parts to cut. But when they happen to be deep, a Surgeon muff ufe the fourth Sort of Lancet, which differs from the others only, becaufc it is much broader and longer, and thereforc it is called an Abfcefs Lancet. THE Scale of the Lancets does generally confift of two fmall Pieces of Tortoife-Shell joined together, the Tongue of the Blade in the middle, by a Nail that goes through thofe three Pieces, and is riveted on both Sides upon two fmall Rivets, 154 A Short Defcription vets, for the more Neatnefs and Security. That Scale is not ftopped at the oppofite end, that it may cafily be opened and wiped on all Sides. A Surgeon ought to be very careful of his Lancets, and get them fet as foon as the Point is not very fharp, and the Edges very fine; for when the Point is a little blunt, and the Edges do not cut finely, the Patients feel much Pain, which makes them withdraw their Arms, efpecially when nothing yet but the Skin is pierced. That fmall Motion does frequently remove the Veffel from its Place, and then a wife Surgeon, who has Anatomy prefent to his Mind in all his Operations, particularly in this, which requires not only a great Dexterity, but alfo an exaC Knowledge of the Part about which he is concerned, thinks it more proper to go away without looking for the Veflcl with his Lancet, than to run the hazard of opening an Artery very often in its Trunk, of pricking an Aponeurofs, a Tendon, or a Nerve, and thereby occafioning violent Pains, great Abfceffes, the Lofs of the Arm, and frequently of Life it telf. The celebrated Surgeons, whom 1 have fo often quoted, obferve that Rule, and I have feen feveral Praatitioncrs who did not fcruple to blood in another Arm or Foot, or to take off and put on again the Ligature, in order to give a fecond Stroak with the Lancet. Thofe great Anatomifts and Surgeons, are very different from thofe, who being ignorant of the Struture and Mechanifm of the fcveral Parts of the human Body, are extreamly well pleafed to fce a Surgeon fail drawing Blood, that they may run down a Perfon whole Merit they are not fo much as able to underftand. SCISSARS of Chirurgical Inifrurnents. 545 SCISSARS are alfo an Inifrument made ufe ofin many Operations. I might be difpenfed with from faying any thing more about them, fince I have defined them, and carefully examined the feveral Parts of which they confift: However, becaufe thofe that are proper for Operations have effential Differences, I fhall fay fomething of them. I have obferved, that thofe Scilffars which are ufed in the Dreffing, might have filver Rings, and afilver Handle: In this Cafe it is the quite contrary; they muff be made of Steel, to be fironger: Beides, the Scifars proper for Operations ought to be crooked or firait, as occafton requires. The crooked ones are always blunt at their Ends, but the ftrait ones are more or lefs fharp-pointed, as occafion fhall require: For Inflance, when the Surgeon muff cut evenly, in certain Places, as in the HareLip; or fcarify CalloFties, as it frequently happens, in Abfceffes, and Fiflulas in Ano, he muft then ufe fharp-pointed Sciffars; in moft other Operations the Blades mut be blunt. HAVING defcribed Part of thofe Inftruments, which are ufed in moft Operations, I fhall now treat of thofe that are peculiar to each Operation; and to do it without any Confufton, I ihall obefcrve the fame Order which I have followed in the Operations. I began with the Reunion of Wounds; and before I lhewed how it might be effeted, I took Notice of feveral Obitacles which prevented that Reunion; wherefore there are two Claffies of Infiruments proper for the Reunion ofWounds,fome are of Ufe to take out extraneous Bodies, and others to bring the Lips of the Wound near one another. AMONG extraneous Bodies, fome are fuperficial, and others in a deeper Situation; the fuperficial N n ones 546 A Sort jDefcription ones arc frequently Small-fhot in the Face, or elfewhere, Grains of Powder, or many other Bodies of that Nature. To take out thofc extraneous Bodies, a Surgeon muff have a fmall Inftrument, called a Scoop. B Y that Word we mean an Inftrument of Steel, Iron, or Silver, like a fmall Spoon, and made Ufe of to take out extraneous Bodies, funk into fome Parts, or to cleanfe fome hollow Places, the Orifice whereof is not very confiderable. This Definition does fufficiently fhew the Conftruf&ion of that Infirumcnt; and therefore I need not defcribe it: I thall only fay, that a Surgeon muff have Scoops of feveral Figures, viz. round, of the fhape of an Olive, and long ones, that they may be adapted to the different Figures of Wounds and extraneous Bodies. Some Surgeons recommend fmall Scoops, fharp on the Sides, to take out fome Grains of Powder, that are fometimes in the Skin of the Face. I own that fince they dcfign to perforate the Skin, in order to convey the Scoop behind the extraneous Body, they avoid, by that Method, ufing many Infiruments: But becaufe the Edges of the Scoop are only of Ufe to cut the Skin a little, and prove hurtful to take out the extraneous Body, I think it is much better to ufe Scoops without Edges to take out the extraneous Body, and to cut the Skin with the Point of a Lancet. VwHEN the extraneous Bodies lie deep, the Surgeon muft know whether they are in the foft or folid Parts if they are in the foft Parts, he takes them out with annulary Forceps's, above-defcribed, taking Care to convey the Forceps into the Wound, to touch the extraneous Body with the Forceps thut; and then to open theE gently, and remove the extraneous of Chirurgical Infiruments. 547 neous Body. Surgeons ufe alfo feveral other Sorts of Forceps's to take out extraneous Bodies, that lic deep in the loft Parts; Inch as the Duck-bill'd, the Crowz-bid'd, and the Crane-bill'd Forceps's. Thofe three Inftruments are made much in the fame Manner; one has its foremoft End blunt and flat; the other more pointed and rounded; and the third, very long whence their different Names are derived; and therefore it will be fufficient to defcribe one of thofe Inftruments. THE EDuck-bilI'd Forceps, is a Chirurgical Infirumenc, to take extraneous Bodies out of a Wound. Since that Infirument is made like a Pair of Pincers, it follows that it confifts of two Branches. Both Branches are rounded, and pretty long from the Nail, whereby they are faftened together to their hinder Part, wherein one may faftllen Rings to have more Strength. From the Nail to the foremoft Part, thofc Branches are like two fmall Spoons lengthened, very crooked, flat and blunt at the End; a Figure not much unlike that of a uack's Bill. I have faid, That the Branches of that Sort of Forceps's were very long from the Rings to the Nail, and very fhort from the Nail to the foremoft End; fo that by fuch a Mechanifm, the Power being at a great Diftance from the fixed Point, it follows from hence, that the Force of the Inftrument rmuft be very great. WHE t I gave an Account of Forceps's in general, I faid they muff have in the Infide different Unequalities at the foremoft Part of their Branches, to anfwer the different UTfes they are put to; and becaufe this kind of Forceps is madc ufe of to N n.z take 5+9 A Sbort Vefcription take out extraneous Bodies that lie deep, and even in the Bones, its Unequalities or Grooves, muff be like a Gratcr, to fecure the Body that is to be taken out. TH E Duck-bi ('d, Cro-w-bil/'d and Crane-biltd Forceps's, differ only by the different Figure of the foremoft End of their Branches, and by their being longer or Ihorter. The Ufe of thof e Infruments confifts, as I have already faid, in taking out extraneous Bodies that lie deep in Wounds. I muff obferve, that all thofe Infirumcnts are naturally opened by a Spring. W H E N the extraneous Body is in the hard Parts, fiuch as the Bones, and the Inftrrnments juff now mentioned are not fufficient to take it out, Surgeons ufe another Infirument, called a Piercer. I T is an Iron, or Steel Ring, with a longaBodkin, which ends by a fimple Screw like a Pyramid, called a Match by the Artifis. That Bodkin is ge-nerally concealed in an Iron C'annuia, at the Entrance of which there ate inwardly 4ýiral Grooves to make way for the Screw of the Bodkin: They contrive in the Neck of the Bodkin a double Screw, an Inch long. The Bodkin muff reach one Inch at leall beyond the 2annu/a, that it may get into the extraneous Body. If the extraneous Body was, for Inflance, a Piece of Iron funk into -the Bone, 'tis plain the Initrument juff now defcribed, could not pierce it, as it would a leaden Ball. In fuch a Cafe, the Bone fhould be trepanned in the adjacent Parts of the extraneous Body, and fome Elcyatories, or other Infiruments, ihould be laid under it to take it our. VfiE E N of Chirurgical Inftruments. 549 WTVHEN the extraneous Bodies are out of the Wouna, the Lips muff be brought together as near as poflible: That Re-union is called Suture, and the Infiruments fubfervient to it, are commonly Needles. THE Needles ufed in the Sutures and Ligatures of the Veflels, are many, and of different Figures, according to the different Sutures, and the different Parts. I have already given a general Definition of Needles, and therefore to avoid Repetitions, I ihall only mention the different Parts of which they confift. Every Needle in general has three Parts, its Head, its Body, and its Point: The Head ought to be lefs bulky than the Body, and the latter muft be lefs broad at its beginning, than towards its end. There are commonly two Grooves in the Head of Needles, one on each Side; and they are longer or fhorter, more or lefs deep, and more or lets broad, according to the different Sizes andDimenfions of Needles, and the Bignefs of the Threads or Fillets that are in part to be contained in the Grooves. From whence it ought to be inferred, that thofe Grooves are only defigned to contain part of the Threads, that they may not much encreafe the Bulk of the Needle, and that they may more eafily pafs into the Flefh without pulling it. There is in the middle of thole Grooves an Opening fomewhat long, which goes through the Needle. THE Edges of Needles muff generally be on the Sides, and in the fame Line as the Eye and the Grooves, becaufe the Edges having made their Openings on the Sides, the Threads which are in the Needle's Eye find a large Way, and pafs through the Flelh cafily, and without any pulling. Nn 3 Br. S50 A Short 7efcriptim B ESI DEs what I have juft now faid about Needies, they have alfo different Figures, according to the different Parts they are to go through. For Infance, thofe Needles that are proper to make Sutures in the Body of the Mufcles, and Ligatures in the Blood-Veffels, are generally crooked, like a Bow, and longer or fhorter, according to the Depth of the Wound. Wherefore Surgeons muft have Needles of three or four different Sizes, and two of each fort, that they may make an end of the Operation, if one of them fhould break. Thofe that are proper in the Gaflrorrhaphy, are differently crooked, as I have faid difcourfing of that Operation. The Needles proper for the Suture of a Tendon, have only one Edge, which is not on the Side, like thoic juff now mentioned, no more than the Grooves and the Eye, as I have obferved in the Chapter concerning the Suture of the Tendon. The Needles ufed for the Hare-Lip, are all ftrait, their Head and Body are perfedly round, but their Point is a little flatted and keen on the Sides, to cut as they pierce, and confequently to get in with more eafe. The Eye of thofe Needles muff be on the fide of the Edges, for the Reafons already mentioned. MOST of thofe Needles, which I have juft now defcribed, being commonly very fmall, and confequently becaufe they give no great hold to Surgeon, it is ufual to add to them fome other Inflruments, whereby they aa more fteadily. THOSE Inftruments are of two Sorts j one is proper for the right Hand, and the other for the left: The firft is called a Port-Needle, and the fecond have different Names according to their Figures, their Ufes of Chirurgical Tnfiruments. 55 Ufes, and the different Operations, to which they are apply'd. THE 'Port- Needle is nothing elfe but a fmall Forceps, the Branches whereof are clofed with a Ring, which fervcs to give the Needles a greater Length, and confequcntly to facilitate their Aaion, when they are too finall. THAT Inftrument conlifs of three Parts, 'viz. an Iron or Steel Stem, fplit at one End, and hollow in the Infidc, like a Funnel, to lodge the Head of the Needle. I mufft obferve that the Grooves, which ferve to lodge the Head of the Needle, ought to be broader towards the Bottom, than at their Beginning, to keep the Needle hteady. However, I fhall fay, that fuch a Caution is often very ufeles; therefore Surgeons uirround the Needle's Head with Linnen or Paper, to firve as a Felt to keep the Needle fteady. The ingenious Mr. 'Petit puts fome Lead into thofi Grooves, and by that Means, without any Trouble, anfwers all the Intentions. The feccond Part of the "Port-Needle is an Iron Ring, with which they keep tight the fplittcd End of the Stem, jufft now defcribed, to bring its two Branches near one another, in order to keep the Needle fall. Mr. Lapeyrronie adds fome Wings to that Ring, and they are the more neceffary, becaui: it is often fo fitraitened that it cannot be loofened. The Surgeon is then obliged to draw the Needle before the Operation be ended, which is inconvenient to the Patient and to himfelf. But when Wings are added to the Needle, they make it more apt to grow loofe. T HE third Part of the 'Port-Needle is the Handle, like a fmall Apple; it may be of Silver,. and mutl have finall Holes upon its hinder Part; whichl, N n 4 as 5 p A Short Deffcription as well as thofe of Thimbles, ferve to drive th Head of the Needle; the Stem, with its Ring, ought to be faftened to the Handle with the help of a Screw. T HE BUk of the Port-Needle, confiffs in holding faft the fmall Needles, to ufe them more eafily, and drive them with the finall Holes that are in the hinder part of the Handle, when they are not far enough, as I have already obferved. THE Helps proper for the left Hand, are two Infiruments, ufually fafltned to the fame Stem; one is a Silver Cannula, in the Shape of a Ring, flat on that fide which muft touch the Parts upon which it is to be applied, that it may be more fleady. That Cannula is open in its upper part to let in the Threads, without being obliged to convey the Cannula all along the Skane or Fillet. The Ufe of that Cannula is to keep falft the Lips of a Wound when they are to be fowed, by reftiing the Force of the Needle that is to go through them, as I have faid in the Operation of the Hare-Lip. 'T I s ufual'to put a Forceps at the other end of the Stem of that Cannula, the two EPranches whereof VrT kept afunder by their natural Spring, but a fquare Ring brings them together to fqueeze the Part. They contrive at the internal end of the Branches of that Forceps, fome longitudinal Unequalities, the better to comprefs the Tendon when it is futured. I have fhewed the Difadvantage of that Inlltument. T HE firft Operations I have defcribed, next to the Sutures, - are the Hernias, the Paracenthe/is, and Hydrocele. THE Infiruments peculiar to the Hernias, are thofe that are proper to dilate a Conftrition. I have of Chirurgical Inftruments. 5 53 have difcourfed of all thofe InfIruments, but I have not defcribed the BifTouri for Hernias. TH A T Inftrumcnt is made up of two main Pieces, viz. a crooked, Iron Cannula, and a Biffouri likewife crooked; that Cannula is pretty large towards its hinder part, and leffens by degrees to end with a very blunt Point. All along the upper part of that Cannula, (I mean in the hollow part) there is a large Groove, which ferves to lodge the Bifouri. The hinder Part of the Cannula ends with a Tongue that goes thjough a Handle, and is flopped upon it with the help of a flat Screw. The Handle is made of Ebony or Ivory, turned, pretty large, and in the Shape of a finall Apple. IN the Cavity ot the Cannula, on the fide of the Handle, there is a Steel-Blade, double and elaflick, the lower Part whereof is ihorter than the upper one, and tied to the Cannula with the help of a iiat Screw, which is turned in the lower part of the Infirument, whilft the upper Part of that fame Blade is tied to no Part at all. It appears by this Decription, that the lower Part of that Blade is unmoveable, by reafon of the flat Screw which faftens it with the Cannula, and that the upper one is moveab e, fine nothing flops it, fo that it may go down when prcffed, and it rifes of it felf by its elaflick Quality, when 'tis no longer preflfd: This is what Artifts call a Double Spring. There is alfo another way of faftening that double elaflick Blade, or that double Spring, viz. by not conveying the large Groove that mufft lodge the Biflouri, as far as the Handle, and to contrive between the Olive-like Eminence, which I am going to defcribe, and the Handle, a Mortife narrower at the Entrance than at the Bottom, that it may receive 455. A 'Short Defcription ceive a Tenon broad in its Bafis, and narrow in its Neck, which is in the lower part of the lower Blade of the double Spring; that ]unaion is known among all the Mechanicks, by the Name of a Swallow's Tail, and it is the fafeft and the moft fteady. Befides that the Tenon and Mortife are like a Swallow's-Tail, that double Spring is alfo faftened with the flat Screw already defcribed. THERE is alfo in the cavity of that Cannula, and at the end of the lower part of the elaftick Blade, which I have juft now defcribed, an Olivelike Eminence, upon the hinder pai t of which there is a pretty deep Groove, wherein the Tongue of the Biflouri is lodged. T HE fecond principal Piece of that Inftrument, is the Biflouri, properly fo called, confifing of two Parts, its Blade and its Tongue. The Blade of the BiJfouri for Hernias, is made like that of crooked Biflouris, which I have already defcribed; it has alfo a round and fmooth Back, the Bevil, a Hollow, and an Edge. However, there is a confiderable Difference, for this Blade is much narrower than that of the common BiJfouris, that it may be exafly concealed in the large Groove of the Cannula. The fecond Part of the Blade of the Biflouri for Hernias, is the Tongue, bored through like all other Biflouris: It is fitted to the deep Groove of the Olive-like Eminence of the Cannula, and ftopped there by a Rivet which goes through the Cannula, the Olive- like Eminence, and the Tongue of the Bifouri; a Mechanifm, which makes up a Hinge. There is in the hinder part of that Tongue, a fmall hollow Tail in the middle of its upper Part, and convex in the lower one 5 it widens by degrees, to forn.aflatand fmooth Blade, of Chirurgical Inftruments. Blade, of a Figure almoft oval, and about one Inch broad; the Surgeon leans his Thumb upon that. Blade, whence it is called the Thurmb's Piece" When he leans his TIhumb upon that Blade almoft oval, it muff, according to the Defeription I have juft now made, come near the Handle, the conver Part of the Tail of the Tongue muft prefs upon the moveable Part of the Blade, and the fharp Blade of the Bv/ouri muft come out of the Cannar la: But as foon as the Surgeon ceafes to lean upon the Thumb's "Piece, the moveable Part of the claflick Blade rifes faiftly, and confequently raifes 'with the fame Swiftnefs the convex Part of the Tail of the Tongue, and turning up quick, the fharp Blade of thic Bij/ouri forces it to retire with the fame Swiftnefi into the Cavity of the Can.nula. I have faid, that all the Screws contained inthat Infirument ought to be flat, that is, they muif not jut out above the Infirument, but be fi-nooth ia that level. However, I mufft obferve, that a fmall Notch ought to be contrived in the middle of their Head, to unfcrcw the Inftrument with a TurnScrcw. I H E Trois- Ouarts is the only Infirument pectliar for Dropfics; it is a Steel-Bodkin, fheathed itl a Cannula, generally of Silver, and made ufe of to pierce fome Cavities that contain Water. I H A Infirument confiffs of two Parts; the firft, viz. The Bodkin, is a fmall Steel RRod, quite round, hafted in its hinder part with a fmall Ivory Handle, not unlike the Head of a Cane, and big enough to hold it in the Hand. The foremoft Part of that fmall RKod muft be four or five Lines in Lengthý and4 fomewhat bigger than the remaining Part SA Short )efcription P art of the Bodkin, to contrive in it three Bevils, Or three Sides, ending with three Angles; whence that Inftrument has been called Trois-Quarts. T H E fecond Part of the Trois-Quarts, viz. the Cannula, is generally made of Silver: We confider in it its Body and its two Ends. The Body is a Tube of a cylindrical Figure, the Cavity whereof is proportioned to the Bignefs of the Bodkin s the foremoft End of that Cannula, is not only open, to let out the Water, the Pus, &c. but it is alfo pierced on the Sides, that the Matter may continually run out, though an Obftrufion fhould be made in its foremoft Opening. That Extremity muft alfo be cut a little Bevil-like in its internal Part, to fit the Extremity of the Bodkin, which is bigger; fo that by this means the Cannula is not bigger than-the foremoft End of the Trois-9uarts, and to make the Cannula ftill more level with the Bodkin, the Angles muff reach beyond the Cannula at leaft by half a Line. THE hinder part of the Canutla ends with a Plate quite round, fomewhat concave on the fide of the Handle, and confequently fbmewhat convex on the fide of the Body of the Cannula. That Plate muft have two fmall Holes in it to let in a Fillet upon Occafion. As foon as the Trois-quarts is driven into the Belly, to bring out the Waters, they come out plentifully; and then they drop only upon the Patient's Skin, which is very unpleafant, and occafions an Itching, that is frequently the Caufe ofan Ery/ipelas. To prevent thofe Accidents, Mr. Petit has invented a peculiar Cannula. Inftead of the Plate of the ufual Cannulas, which I have juft now defcribed, he ufcs a kind of Spoon, much longer than it is broad, of Chirurgical Inftruments. 7 broad, into which the Waters run; and they m,. be gathered by putting a Veffel underneath.. Tha, Spoon projeds a little outwardly, that it may not hinder the Handle of the Bodkin from getting in aind coming out. The fame Spoon is attended with another Advantage, which is very confiderable, fince it ferves inftead of a Handle to the Cannula, when an Abfccfs is to be. opened; for the Cannula has been opened all along its Body by the Diredion of that Surgeon, and therefore it performs the Part of a grooved Probe. LASTLY, a Surgeon muff have fome Trois-quarti of different Sizes, according to the different Parts, and the feveral Patients, that require the Ufe of that Inftrument. HAVING defcribed at large the Inftruments proper for the Operations of the Abdomen, I proceed to thofe that are ufed in the Operations of the Bladder, of the Parts depending upon it, and of the Anus. THE Inftruments which concern the Operations of the Bladder, and of the Parts depending upon it, are of three Sorts; fome are ufed in the Outfide of the Penis, others in the Urethra only, and others bothin the Urethra and Bladder. A SMALL Penknife is the only Inftrument we make Ufe of for the Outfide of the Penis. THE antient Surgeons had an Inftrument, the fharp Blade whereof being fomewhat like our ufual Penknives, moved them, perhaps, to give it that Name. To know that Inftrument well, it ought to be divided into three Parts; thefirft is a fmall Steel Blade, fharp on the one Side, and rounded on the other, which is called its Back; It is about five or fix Inches long, and two Lines broad, in its Beginning, A Short?)fcription Aing, from whence it lellens by Degrees to its Point The fecond Part of that Inftrument is its Tongue, ihaped like the Handle of a Mill, being twice folded like a Hand-fpit, which reprcents two right Angles. At the hinder End of the fecond Angle, there is a Tongue, which gets into the third Part of that Intrumecnt, viz. the Handle: That Handle is generally of Ebony, as big as the little Finger, and about three or four Inches long. THE Ufe of that Inifrument confifts in cutting the Skin of the Prrputium, when there is a Phimiofis: Its fharp Point muff then be covered with a fmall Wax Ball. But I have fhewed elfewhere, that fuch a Precaution is very ufelefs, when the Inflammation is confiderable; and that a better Succefs may be expeded from the Biflouri for Hernias, which Mr. Lapeyronie has enlarged. THE Infiruments made iUfe of only in the Urethra, are the Wax Candle Cafe, and the Wax Candies, of which I fhall fay nothing, fince I have not mentioned them in the Operations. THE Infirunments made Ufe of both in the Ure. thra and Bladder, are thofe that are proper for probing, making Injedions into the Bladder, and extrading the Stone out of it: The firft are the Stone Forceps, and the grooved Probes, upon which I have liufliciently enlarged in the XVIth Chapter, where I difcourfed of the Method of probing in the Difcafes of the Bladder; and in the XVIlIth Chapter, wherein I defcribe the grooved Probe. Syringesr are made Ufe of to convey Injedions into the Bladder; but I (hall be filent about them, becaue I have already defcribed them. THE fecond Infirument that gets into the Bladder is. the BIftouri for the Stone, otherwic 4lalcd Lithotonus. To of Chirurgical Inftruments. 9 To have a right Notion ofthis Inftrument, I fh~4t firlt confider its Blade, and then defcribe its Handle. All fharp Infitruments ought to be made of Steels and becaufe the efliential Property of the Lithotomus is to cut finely, it ought to be made of good Steel: The Blade of that Infirument confifts of two Parts; one is the Blade, properly fo called, and the other its Tongue; the Blade, properly fo called, is all that Part of the Lithotomus contained out of the Handle. The Tongue of the Lithotomus has a Hole in it, to let in the fame Nail that goes through the two Wings of the Handle or Scale; that Nail is riveted on both fides of the Scale, upon Rivets fhaped like Rofes, generally of Silver. At the hinder End of the Tongue there is a long Tail, ending with a tranfverfal Tail. THE Handle, or to fpeak more corretly, the Scale of that Biflouri confifts of two Tortoife-fhells very parallel, flat inwardly, and fomewhat convex in their external Part. They are applied in one of their Ends, upon the Sides of the Tongue of the Blade, where they are flopped with a Nail, which goes through thofe three Pieces, as I have already faid; but the other End opens like the Scale of a Lancet, and for the fame Reafons. About the middie of the upper Part of that Handle, there is a finall Notch, which ferves to lodge the Lentil of the Tail of the Tongue, that the Blade may be unmoveable in its Scale, during its Operation. TH E Ufe of that Inftrument confifts, in cutting the 'Perinieum, as I have faid, difcourfing of the Lithotomy. THE third Inflruments, that get into the Bladder, are the Male and Female Condudors. T HO s Infiruments are generally of Silver a they 5 6o A Short Vefcrzpiion. they are like a Crofs, eight or ten Inches-long; the upper Branch 'of that Crofs muff be very much inverted, to leave*'a greater Space between the two Conduftors, for the freer Pafage of the Stone Forceps. They contrive upon the Body of that Crofs, a kind of Rib, that projeds out, which begins infenfibly upon the middle of tnie convex Part of the upper Branch, and encreafes by degrees, till it reaches beyond the.Arms of the Crofs. Afterwards it goes in the fame Size to the Foot of the Crofs, where it ends at one of thc Condudlors with a Button jutting out and hatted on the Sides 5 which is the Reafon why that Inftrurent is called the Male Condudor. But in the other it does not go quite fo far: On the contrary, it eems to difappear, by dividing into two, which occafions a hollow Cut, with which that Infirument ends, and from which it has been called the Female Condudor. T E r Ufe of thofe Inifruments confiffs in conveying the Stone Forceps into the Bladder, as I havc Ihccw'cd in the Operation. TH E fourth Infirument that gets into the Bladder, to extrat the Stone, are the Stone Forceps, the Button, and the Hook. The Stone Forceps, is a kind of Forceps, the foremoff Ends whereof arc like very long Spoons, which ferve to take the Stones out of the Bladder. THE Stone Forceps confiffs of two Parts, like two very long S's, each Picce is divided into two Parts; the firfi is the Ring, which is much larger than thofe of ScifThrs) becaufe the Forceps are often held with both Hands3; its Conflrudfion is not the fame neither as that of the Rings of Sciffars, whiTh are fomewhat long and fatted, as I have faid of Chirurgical Infturuments. 561 faid above; but the Rings of the Stone Forceps muff be round, and formed by the Circumvolution of the End of the Branch. What is next to the Ring, as far as the Jundion, is called the Branch; it mull grow larger by degrees, to have more Strength, that it may not break when the Surgeon ftrives to take out the Stone. Its Figure is cylindrical, and perfealy finooth; it is alfo a little crooked, to leave a fpace between the Branches, that the Parts may not bepinched. What is next to the Branch, reprefents the middle of an S, and is confequently crooked both Ways; that Place is alfo broader than the Branch, and very much rounded in all its Angles; it has internally a Depreflion, which joins in with the Depreflion of the other Piece. That JunCion is faftened with a Nail well filed upon the two Pieces, fo that it is level with them, and does not jut out at all. THE fourth Part of the Stone Forceps, is what we call their Holds; they are two Sorts of Spoons, very long, concave in the Infide, and convex in the Outftde. The convex Part muff be very fmooth, and the concave muft be fo, only from the Nail to one half of the Holds, for fome eflential Reafins, which I have mentioned in the XVIIlth Chapter. But the remaining Part of thofe Holds muff be provided with finall tranfverfal Grooves, thick fet with feveral Rows of Teeth, like Graters, to refift extraneous Bodies. - Thofe Holds ought to be fomewhat crooked, to leave between them a Space, which ferves not only to enlarge the Cavity of the Spoons, but alfo to prevent the Bladder's being piiched when they are thut. Lafily, The Stone F4rceps in general, muft be very finooth, efpccially the Angles of their Joints, to avoid pinch0o ing 56 s A Short Defeription ing the Flcfhl. Bcfidcs, they ought to be of good Steel, and of a Temper neither too hard nor too foft, for thofe two Extreams are dangerous; by the former they break upon a great Effort, and by the latter they yield and become pliant, which is as great an Inconvenicncy. THE Stone Forceps's are not all equal; fome are firait, others crooked, larger, of a middle Size, or ihnall, according to the different Ages of the Patients, and the different Situations of the Stone. THE Button, confidered as a Button, is a kind of Probe, made ufe of to get into the Bladder, after the Extrafcion of a Stone. To have a right Notion of that Infitrument, one muft know, that it is a Rod generally made of Silver, a Foot long at moff, and larger at one End than at the other; But becaufe that Infitrument contains two others, I fhall defcribe its Body and its Extremitics. THi I;ody of the Button is of a cylindrical Figure, which having a pretty large Bafis, leffens by degrees, and then becomes crooked, and ends with a Button. All along the cylindrical Body, on the Side of the Crookcdnefs of the Button, there is a Spine which, like thofe of the Conduaors abovementioned, performs alfo the Part of a ConduCtor, to introduce the Stone Forceps into the Bladder a fecond and a third Time, if it be Ieccffary. The other End of the Button is much broader, it is hollow over-againft the Spine, and like a very long Spoon. THE Ufe of thofe Infiruments confifts in introducing the Button into the Bladder, to know whether there be a fecond Stone; in conveying the StoneForces along the Spine; and taking out the Fragments oJ Chirurgical Inftruments. 563 Fragments of a Stone, or the Clods of Blood with the Spoon. THE Hook is the laft Inftrument made ufe of for the Extration of the Stone. It is a kind of Spoon of Iron or Steel, half a Foot long together with the Handle; I fhall therefore defcribe thofe two Parts. One may confider the Middle and the Ends of the Hook; the Middle is an Iron or Steel Stem, perfeely round and fmooth, but bigger on the Side of the Handle: The foremoft End of the Middie of that Infirument makes an Elbow, and then bends in the Shape of half a Crefcent, and forms in that Bending a pretty long Cavity, which, at its End, muft be armed with fmall Teeth, like a Grater: The other End is a round Piece of the fame Matter, convex and fmooth on the Side of the Inftrument, but flat and coarfely filed on the Side of the Handle, upon which it is to lean. This is called by Artifts the Button of the Hook. From the Middle of that Button proceeds a Tongue which is cemented in the Handle with Maftick: The Handle is generally of Ebony, and has the Figure of a Pearl. THE Ufe of that Inftrument confifts in extra&ing the Stones that are in the Paffage, either in the fmall Apparatus or otherwife. To make an end of the Inftruments peculiar to the Operations of the Abdomen, I proceed to the Royal Bifouris. THOS E Biftouris are made much after the fame manner as thofe which I have already defcribed. They are narrower and longer; their Point is alfo different, for the common Bifozris are fharp-pointed or blunt 3 the latter end with a fmall Probe, three or four Lines long, and with a Button at its 00o z nds 564. A Short iDefcription cnd, or with a Point, in which there is an Eye to pafs a Thread. Thofe Biflouris are three in number, a firait one, and two crooked; a ftrait Biflouri, and one of the crooked, have the fmall buttoned Probe at their end, and the other is bored hr ough, as I have juft now Laid. TH E royal Bifiouris have been fo called, becaufe the crooked one, with a Button at its end, was ufed upon Lewis XIV. They are only proper when the Filula in Ano is compleat, and not very deep. HA VIN CN defcribed thofe Infiruments that are ufed in the Operations of the Abdomen, I proceed to defcribc thofe that arc peculiar to the Breaft. THE y are not fo numerous as thofe of the Abdomen 5 they are common to many other Parts: For Inftance, we have no other Infitrument for the Emrpyema, but the Biflouri, which is common to tivcral other Operations, and a Cannula, of which I have lbched the Difadvantages. INSTRUIMENTS proper for a Cancer, may alfo be uifed in all incified Tumours which happen in the feivcral Parts of the Body. Thofe Infiruments are a Stone Forceps, a Razor, and a double Errhine. Thofe Stone Forceps's are called Helvetian, becaufe Dr. Helvetius invented them; they are like Pincers, and confift likewife of two Branches, a Male and a Female one, that they may be united by an infide Joint. Each Branch may be divided into three Parts, viz. the Ring, the Branch, properly fo called, or the Handle, and the half Circle or Crefcent. I have fhewed in the XXXth Chapter, that a Surgeon may be without that Infirumcnt; and therefore I give but a fuperficial Defiription of it, THE of Chirurgical Inftruments. 565 THE Razor, proper for the Operation of the Catcer, and incifted Tumors, is made much after the fame manner as common Razors; but it is much thicker, becaufe the Tumors to be cut with that Razor make a greater Refiftance than the Beard to a common Razor. Befides, the End of that Inftrument ought to be blunt, and very much rounded, both in the Edge and Back, that the Operator may not run the hazard of cutting his Fingers. The Blade of that Inftrument is kept open with the help of a fmall Iron Groove, which is fet in two fmall Grooves, lying in the Infide of the Scale. Betides that the Infirument muft alfo be made fteady with fome Turnings of a Fillet. I have preferred to that Infirument the common Bifouri moderately crooked; but if a Surgeon had a mind to ufe it, I would have a Tail to be contrived at the hinder Part of its Tongue, and I would put at its End a Lentil, that fhould get into a Notch in the Scale, as I have obfervcd, fpeaking of the Lithotomus; and the whole might be faftened with fome Turnings of a Fillet. T H E Errhine made ufe of in incifted Tumors, is a kind of Steel Fork, the Ends whereof are crooked. T AT Inftrument is halfa Foot long at moft. It confifts of a Stem, perfedly round and fmooth, and ending at one of its Ends, with a Button leaning upon the Handle. From the Middle of the Button there arifes a Tongue, which gets into a fmall Handle, and flicks to it with Maftick. The other End of the Errhine is divided into two Forks, four Inches long, very fharp at their End, and crooked, like Hooks. T H A T Inftrument is mounted upon a Handle, generally of Ebony, as big as the little Finger, 00o 3 and 566 A Short Defcription and two Inches long; it is made with Facets, that it may have more Surfaces. THE Ufe of the Errhine confifts in catching the fmall diftended Glands, which have not been been taken off with the large Tumor, in order to remove them; for they would occafion a new Difcafe. T H E next Part to the Breaft, according to the order I have followed hitherto, is the Neck, upon which I have only defcribed the Operation of the Bronchotomy; and therefore we have no Inftrument peculiar to that Part, but the finall Cannula, which is introduced into the Opening made in the Wind-Pipe. That Cannula is very fmall and flat. In a word, its Dimenfions are one Line, or one Line and a half in Diameter at moff, three oi four Lines in Breadth, and five or fix in Length. There are on both fides of its upper Part, two fmall Loops to let in two fmall Fillets; it is a little crooked anteriorly toward its lower Part, to humour the Motions of the Wind-Pipe, and is rounded upon the Sides to avoid touching it. THE Ufe of that Cannula confifts in letting out the Air contained in the Wind-Pipe, and keeping the Air from getting into it. THOUGH I have defcribed no Operations in the Mouth, yet there happen frequently Difeafes in that part, which require the Help of a skilful Hand. Among the Difeafes incident to the Mouth and the adjacent Parts, there happen fometimes great Inflammations and Swellings in the.Amygdales, and frequently large Abfceffes, becaufe thofe Glands are in Clufters like a Bunch of Grapes. It is ufual to blood plentifully in the firft Difeafe, but when after much blooding in the Arms, the Foot, incr in Foot of Chirurgical Inftruments. 567 and the Jugular, the Swelling continues, the Surgeon is obliged to make Scarifications upon thofe Glands. As for Abfcelfes, the beft and quickeft Remedy is to open them; but becaufc it is no eafte thing to operate in thofe Parts, in either of thofe two Cafes, Mr. Petit has invented a very convenient Inftrument, which he calls Pharingotomus. I is a Lancet concealed in a Cannula, which comes out upon pufhing a fpiral Spring, and with which a Surgeon may eafily fcarify the Amnygdales, and open the Abfcefles contained in them. I LOOK upon the Pharingotomus as confifting of three Parts, a Cannula, a Stilet, and a Spring. Again I divide the Cannula into two Parts, the upper and the lower one the upper Part of the Cannula is pretty like a fmall Syringe for Inje&ions; I mean that it is made like a imall Bore of a Gun, perfectly cylindrical, having in the Middle, and upon its Extremities, fmall Circles, not only for an Ornament and for Symmetry, but alfo to hold the Inftrument more fteadily. That Cylinder is hollow, very finooth in the Infide, and about three Fingers long. They folder upon the Middle of that fmall Bore, a Ring perfetly round and fmooth, in which the Surgeon puts his middle Finger, the fore Finger upon the other Side of the Bore, and the Thumb upon the Button, which I am going to defcribe. TH E lower Part of the Cannula is the Cannula properly tb called: It is of the fame Matter as the Cylinder juft now defcribed; and a Silver one is is the neateft and moft proper. That Cannula is fix or feven Inches in Length, three or four Lines in Breadth, and one Line, or one Line, and a half in 0 o 4 Diameter; 568 A Short Defcription Diameter; fo that it is long, not very broad, and very flat. ALL the Pharixgotowms's, which I have feen, have that Cannula well foldered uporn the lower Part of the fmall Bore juff now defcribed, which I look upon as a great Fault in that Inftrument. I had rather it fhould be mounted with a Screw, for the Reafons whiich I fhall mention hereafter. THE fecond Part of the Pharinaotomus, is the Stilet: It is made of Silver,.as well as the whole Cannula, and two o-r three Lines longer than the whole CannulaC; t Le tw0o third Parts of its Body ought to be flatted, in order to fit the Cavity of the Cannula 3 its two Ends are differently made, one of them is flit, to adapt to it a full-pointed Lancet, the Point whereof muff not be very fharp; for it would foon be blunted; the other End is perfettly round, and like a fmall Cylinder for the Space of two Inches, at the End of which there is a fmrall Button, in the Ihape of a Pearl dilated in its upper Part, and provided upon its Top with finall threaded Grooves, to receive the Thumb upon an uneven Surface. An Inch under that fmall Pearl, there is a fmiall circular Plate, placed horizontally, and foldered in that Place; or elfe they folder inflcad of it a finall crofs Bar, of the fame Length as the Diameter of the Cavity of the Bore; which reprefents the Figure of a Crofs. The Ufe of the Plate or crof Bar conlifts in leaningcr upon the Spring, drivýng it towards the lower Part of the Bore, and keepincr the Stil/et from rifing more than it ihould. LASTLY, the third Part of the ~Pharingotomus is a fpiral S&pril, confifting of a Steel Wire, very elaftic, anld twifled like a Cork-fcrew. They put that Spring into the Bore above deferibed; ifo that when of Chirurgical Inftruments. 569 when the Button of the Stilet is fqueezed, the fmall crofs Bar, or the finall circular Plate, brings the Threads of that Spring near one another $ whereby the Stilet may move towards the Extremity of the Cannula, and the Lancet may quite come out to make Scarifications, or open an Abfccfs. Affoon as the Surgeon gives over prefling the Button with his Thumb, the Spring removes it from the Part, and the Lancet gets into the Cannula again, and frequently all bloody, and covered with Pus. That Inftrument mufft be taken to Pieces, in order to be cleaned; and if the Bore opens in its upper Part, the Surgeon muft be feeling and trying, for the Space of an Hour, to pafs a Fillet into the Cannula; (for it ought to be paffed in its upper Opening;) but what is moft inconvenient, is that the Lancet muff be put again into the Cannula, and to that end it muft be conveyed into the Cavity of the fpiral Spring, which cannot be done without a great deal of Time, or without taking off the Point of the Lancet; I am therefore in the right, when I am for fcrewing the Cannula upon the Bore. T H E Infirument peculiar to the'Polypus, is a Forceps with Rings, which I have already defcribed, as well as thofe Inftruments that are proper for the Fiflula Lacrjmalis. However, I fhall obferve, that Cauteries ought not to be cemented in the Handle with Maftick 5 for the Fire heating very much the Tongue of the Cautery, it melts the Maftick, and the Inftrument comes out of the Handle. On the contrary, the Cautery mufft be fcrew'd upon the Handle, or its Tongue muft be fquarer and riveted at its End. T HE laft Clafs of Infiruments that make Divifions, takes in thofe which are ufed upon the hard Parts, 57o A Short Defcription Parts. Thofe Sorts of Inftruments are of feveral Kinds, as well as thofe made ufe of in the foft Parts, which I have juft now defcribed. I fhall begin with the Infiruments peculiar to the Fradtures, a Difcafe which happens in the Bones, efpecially in thofe of the Scull; and therefore I fhall take a View of the feveral Pieces which conftitute the Trepan. I N order to examine the different Inftruments, of which the Trepan confifts, they muft be reduced to three Kinds. Thofe of the firft Kind are made ufe of to lay the Bone open; thofe of the fccond pierce and faw it; and the third cut the Unequalities left by the Coronet, raife the Pieces that are funk, and ferve in the Dreflings. THE Inftruments of the firft Kind, are of two Sorts: fome are common to moft Operations, and others peculiar to the Difeafes of the Bones. The former are the Probes, the Razor, the Bifouris, and feveral others, which I have defcribed in their proper Places. The latter are the Rugines. B the Word Rugine, I mean a kind of Rafpatory, which ferves to fcrape and uncover the Bones. T HE Rugine muff be confidered in its Body and its Extremities; the Body of the Rugine is a Silver Stem, four Inches long, perfetly round, and fmooth towards its foremoft End, but fhaped Facetwife in the Middle of its Body, which grows larger as it comes nearer the Handle, where it ends with a fmall circular Plate applied to the Handle, and called the Button. From the middle of that Button proceeds a Tongue two Inches long, which is the hinder End of the Rugine, and cemented with Maftick in the Handle. The foremoft End is a Steel-Blade well tempered, an Inch long, three or four Lines broad, fharp in its Circumference, and of a different Figure, of Chirurgical Inftruments. 57 gure, according to the different Parts that are to be fcraped; fome having one of their Ends long, others having a crooked Point, and the laft being perfecly fquare. THE Handle is generally of Ebony or Ivory, four Inches long, and of a proper Bignefs to hold it in the Hand conveniently. TH E Inftruments of the fecond Kind, are all the Pieces, which make up the Trepan j they are pretty numerous, and very different. I cannot better define the Trepan, than by faying, that it is an Iron or Steel Wimble, confifting of two Pieces, viz. the Trepan, properly fo called, and the Arbor which fupports it, defigned to pierce and faw the Bones, but efpecially thofe of the Scull. THE Trepan, properly fo called, is of three Sorts; one is called Exfoliative, the fecond Perforative, and the third the Crowned. THE Exfoliative Trepan, is aPiece of Steel, four Inches long, fharp in its lower Part as well as the Wimble of Coopers, to make a large Hole, and to remove the fhaking Lamineof the Bones. IN order to examine that Inftrument in all its Parts, I muff confider its Middle and its Extremities. The Middle of the Exfoliative Trepan, is a Steel Stem, perfefly fmooth, divided into two Handles, the one round in its Circumference, and the other like a Pearl, cut Facetwife, for the Beauty of that Inftrument, and to handle it more fteadily. The upper Part of that Inftrument is a circular Plate, convex and fmooth on the Side of the Stem, but flat and caorfely filed upon its upper Part, that it may more exatly be fitted to the unmoveable Pivot of the Arbor of the Trepan. That fmall Plate is called by Artifts the Button of the Exfoliating Trepan. 572 A Short Defcription pan. From the Middle of that Button there arifes, in fome Inftruments, a Stem perfealy fquare, and an Inch high, upon one fide of which there is a tranfverfal Groove, engraved for fuch Ufes as I fhall mention hereafter. In other Inftruments, that Stem is cylindrical, and turned like a Screw, whofe Threads are fomewhat large. I fhall fhewthe Ufe of thofe Differences. THE lower Part of the Exfoliative Trepan, is a Kind of fquare Blade, two Lines thick in its upper Part, fomewhat lefs in the lower one, an Inch broad, and one Inch long. From the Middle of the lower End of that 'Blade, there comes out a fmall Wick, a Line and a half loing at moft, which from a broad Bafis ends with a Point. That Blade, which is perfealy like the Wimble of Coopers, muff have fix Edges, which are all oppofite; there are two upon the lateral Parts of the Blade, two in its lower Part, and two on both Sides of the finall Wick juft now defcribed. Thofe Edges are perfe& Bevils, turned from the Right to the Left, to cut from the Left to the Right. Laftly, that Blade muft be of good Steel, and well tempered. THE fecond Kind of Trepan, is the ~Perforative, fo called, becaufe it pierces. It is made of the fame Matter as the foregoing, and differs from it only, becaufe its lower Part, which is the Blade, ends with a fharp Point on the Sides, not unlike the Figure of a Pike. The moft common Ufe of that Inftrument, is to make a Hole upon the Skull, in order to put into it the Pyramid of the Crowned Trepan, and therefore its Point ought to be proportioned to that of the Pyramid. But the Surgeon may frequently ufe it to make feveral Holes upon other Bones, for tfltancc, upon fome Evxoflofes, that of Chirurgical Infiruments. 573 that he may afterwards take them out with the Chiffel and Mallet. LASTLY, The third Trepan, which I have called the Crowned, is like the two foregoing in its Middle and its Extremities. It muft alfo be of the fame Matter, I mean, of good Steel; but this ought not to be tempered, for fome obvious Reafons, made good by conftant Experience. THE lower Part of that Inftrument is like the Figure of a Crown, which is the Rcafon whyj it has been called the CrownedTrepan. Ifwe confider it inverted, we may compare it to a Bufhel of one Inch and a half in Height, and one Inch in Diameter. The Bottom of the Cavity of thatVeffel, muff have a greater Diameter, and confequently a greater Circumference than the Entrance, that the Piece of BoCie which the Surgeon faws, may enter and afcend into the Bufhel without Refiftance, as the Crown finks. The Cavity of that Bufhel muft alfo be per'fetly round, and pretty fmooth, that the Piece of Bone may not catch in it: but its external Part, as well as the internal one, is broader towards the Bottom of the Bufhel, and infenfibly defcends and diminifhes. That Mechanifm is of no fmall Importence, fince by that means the Coronet faws the Bone bevil-like, and the Bone is cut in fuch a manner, as to be able to fupport the Coronet, and keep it from falling all of a fudden upon the VDura Mater. Laftly, The Outfide of the Coronet is jagged, with two and twenty, three, or four and twenty Bevils, turned from the Right to the Left; they lie, as it were, upon one another, and form fome Edges likewife from the Right to the Left. Thofe Bevils do not fall in a perpendicular Line, from the upper Part of the Crown to the lower; but they 574. A Short Defcription they defcend obliquely, to cut the better. Laffly, each Bevil ends with a fmall Tooth, which forms, together with the reft of the Bevils, a circular Saw. TH E Teeth and the Bevils of the Crowned Trepan grow blunt, and wear out as well as (harp Inftruinents, and therefore they muff be mended now and then, or new ones muft be made. Sharp Inftruments cannot be mended or fet, but with a GrindStone, by reafon of their Temper. I T appears from the Defcription I have given of the Crowned Trepan, that its Teeth and Bevils cannot be fet upon a Grind-Stone; a File is therefore neceffary tomend them. Now, I defire all Surgeons, who will have the Coronet to be tempered, to tell me whether a File can affcet a well-tempered Steel; and becaufe the Thing is impoflible, I conclude, that the Coronets of Trepans ought not to be tempered. Befides, it has been obfcrved, that when the Coronets were tempered, their Teeth broke every now and then; which moved great Surgeons to advife their Scholars to get two Coronets of the fame Size, that when one of them happens to break, the other might fupply its room. T o make an end of the Defcription of the Crowned Trepan, it remains only to difcourfe of its Pyramid, and the Key, which fcrews and unfcrews it. The Pyramidof the Crowned Trepan, is a Kind of Perforative, or rather, a Bodkin, of the Length of the Crown. That Pyramid ought to be confidered in its Middle, and in its Extremities. The Body is perfetly fquare, that it may be turned with the Key. The upper End (I confider all thofe Infiruments in their proper Situation during the Operation) is a Screw, turning contrarywife, that it may not relax in the Operation of the Trepan. The lower End of Chirurgical Inftruments. 575 End ought to be made in the Shape of a Serpent's Tongue, fharp on the Sides, and pointed like the Perforative. TH E Key is an Iron Inflrument, confifting of a Ring very irregular, having frequently the Figure of an O&agone, fometimes of a Cube, and often like Trefoil. In one of the Extremities of that Ring, there is an Iron Stem two Inches long, and as big as a large Quill; that Stem is pierced fquare along its Body, to receive the Body of the Pyramid, which I have faid to be of a fquare Figure. THE Arbor of the Trepan is like the Wimble of Joyners, I mean, that it is, as well as that Inftrunent, made up of a Handle and a Branch bent Elbow-like. I confider two Parts in that Branch; the firft is the Branch of the Trepan, and the fecond contains two Pivots, upon which the Branch appears, as it were, foldered, though thofe two Pieces make up but one. That Branch may be further divided into three Parts, the two firft whereof are placed horizontally, and, as it were, foldered upon the Pivots; and the third is perpendicular, and, as it were, foldered upon the Extremities of the two horizontal Branches. There is in the Mid. die of that perpendicular Branch, a Steel Head, as big as a fmall Nut, and having in its Circumference fmall perpendicular Furrows to prefent unequal Surfaces to the Fingers of the Hand that is to hold it. One of the Perfetions of that Head, confifts alfo in turning about its Axis, which very much facilitates the Operation of the Trepan, and is not fo troublefome to the Surgeon. THE Pivots of the Arbor of the Trepan, are two in Number, viz. the upper and the lower one; or to exprcfs the Thing according to the Language.of 576 A Short efcription of Artifts, one is moveable, and the other unmoveable; the moveable, or the upper one, is five Inches long. We confider in it three Parts; the upper one is a round Tongue, as big as a Quill, and two Inches long; that Tongue is thruft into a fmall Handle of Ebony or Ivory, well turned, of the fame Length, and as big as ones Finger; and it is riveted in its upper Part, upon a fmall, roundPiece of Iron. In the upper Part of the fmall Handle, there is a Screw, which is faftened to a Handle of the fame Matter, and of a flat Figure, circular and fymmetrically rounded in its Circunmference. The middle Part of the moveable Pivot, is a Stemn likewife of Steel, confifting of a fmall, round Head, in the Shape of a Pearl, in the upper Part of which there is a round Piece, which leans upon the Handle, and is called the Nut of the Pivot. Laftly, The lower Part of that Pivot is one Inch long, it is cut with eight Sides, to one of which adheres one of the horizontal Branches: It ends with a Button, very fmooth, and like the Figure of an Acorn; that Pivot is called moveable, becaufe its Tongue turns in the fiall Handle of Ebony, which I have juft now defcribed. T HE unmoveable, or lower Pivot, appears outwardly to be like the lower Part of the moveable Pivot j but the former is hollow in the Infide, to lodge the Stems of the Trepans above defcribeds and becaufe that Stem is of different Figures in different Trepans, it follows, that the Cavity of the unmoveable Pivot muft be fquare or round, to fit the Stems of the Trepans. When the Cavity of the unmoveable Pivot is fquare, that Pivot muft have one of its Sides open almoft in its whole Length, to put it into a Spring of the fame Length; that Spring of Chirurgical Inftruments. 577 Spring confifts of two Pieces; the firft is a Steel Blade, pretty ftrong, in the upper and external Part of which there is a fmall Button, round and very fmooth. In the middle of its internal Part there is an Eminence cut out floping, and pierced by a Hole that goes through it; this is called the Tenonof the Spring and a little farther, towards its lower Part, there is a round Eminence likewife cut out, floping and very fnooth, called the Nut of the Spring. The fecond Piece of the Spring, 'is a fmall Steel-Bladc, very elaftick, faftened near the Tenon, and which projects towards the upper Part of the Spring, and goes from it. That Spring is mounted in the immoveable Part of the Arbor of the Trepan, with the help of a flat Nail, which goes through the Pivot and the Tenon, fo that when the fquare Stem of one of the Trepans is introduced into the fquare Cavity of the Point of the Arbor, the Nut of the Spring gets into the tranfverfal Groove, engraved upon one of the Sides of the Stem, which keeps the Trepan pretty faft in the Cavity of the Pivot of the Arbor. But when the Surgeon dcfigns to take off the Crowned Trepan, or another, he lays his Thumb upon the Button of the Spring, bywhich means it turns up, and the Surgeon takes off the Coronet. WH EN the Cavity of the unmoveable Pivot of the Arbor, is round, it is fafhioned internally with fpiral Grooves, which ferve to receive the Threads of the Screw, to be found about the cylindrical Stems of the Trepans. Thofe Grooves are made contrarywife, to prevent the Trepan's being difnidinted in the Operation. P p 578 A Short Defcription IN order to make an end of our Reflecions upon the different Pieces of the Trepan in general, I fhall fay fomcthing about the Inftruments of the third Kind, which ferve to cut the Unequalities left by the Coronet, to raife the Pieces of Bones that are funk. THE Inftrument proper to cut the Unequalities left by the Coronet, is the Lenticular Knife; That Infirument is made like the Rugines, only with this Difference, that it ends with a Knife two Inches long; all Artifls make one Side *of that Knife flat, which I very much approve; but I do not approve fo well the convex Figure which they give to the other Side of that Inftrument, becaufe its Edge cannot then reach the Unequalities to be found at the Circumference of the Hole of the Scull, unlefs the Surgeon take a particular Care. There is in the lower end of the Lenticular Knife, a fmall Button, very flat and fmooth, to go over the Dura Mater, without hurting it. TH E Initruments proper to raife the Pieces of of Bones that are funk, go by the Name of Elevatories; that Inftrument is a Kind of Leaver, above half a Foot long, adorned with fmall Heads in the Middle, but ending with two Branches, one of which is crooked on one Side, and the other on the other Side. Thofe Branches are made Facet-wife, to hold that Leaver more fteadily; and they grow flat and broader, as they come nearer the Extremity, where they end with fmall tranfverfal Grooves, which are made like fmall Bevils, lying one upon another, and which feem to proceed from the Extremity of the Branch towards the Middle. The Branches of the Elevatorics of Chirurgical Inftruments. 579 v4tories are differently crooked, fome being almoft ftrait, fome a little more crooked, and fome very much turned Elbow-wife, to ferve fometimes as a propping Point. Laftly, The Extremities of the Elevatories end alfo differently, fome being rounded at the End, fome of an Olivelike Figure, and others fquare. THE particular Inftrumcnt made ufe of in the Dreffing of the Trepan, is called Mleningophylax; its Struture is like that of the Lenticular Knife, only with this Difference, that the former has no Edge; but in its room there is a fmall Cylinder, perfctly round. THE Ufe of that Inflrumnelt confifts, in leaning upon the VDura Mater, whilft the Patient makes a great Expiration, to let out the Blood or Pus that is diffufed 3 that Inftrument is commonly made ufe of to drels the Opening of the Scull; but I prefer the fmall Leaves of Mr. Petit, which I have defcribed in the XLth Chapter. To make an end of the Defeription of thofe Inftruments that are proper for the Operations of Surgery, it remains only.that I thould difcourfe of thofe that are made ufe of to cut off the Limbs. TH R E E Sorts of Inftruments muff be ufed for the Amputation of Limbs, the firft ferve to cut the Flefh about the Bones, the fecond to faw the Bones, and the third to flop the Blood. THE Flefh about the Bones, is cut with crooked and ftrait Knives 5 the crooked Knife, or the Knife of Amputation, is almoft one Foot in Length; its Figure is half a Crcfccnt; it is three Inches broad near the Handle, and leftens by degrees, till it forms a Point: Its Back is pretty thick, and perfe&ly Pp 2 fmooth 5o80 A Short Defcription fmooth in its whole Length, wherein that Knife differs from that of the Antients, which had' a Ridge in its Back to fcrape the'PerioJfleum. There is alfo in that Knife, a Plate cut with eight Facets, fomewhat convex on the Side of the Blade, and perfctly fmooth, but flatter on the other' Side, and coarfely filed, that it may the more exa&ly be fitted to the Handle. That Plate is called the Button of the crooked Knife; near that Plate the Blade of the Knife juts out about one Inch 3 that Projc&ion is pretty round, and very blunt; it ferves for a Prop to the Thumb in the Time of the Operation 6 This is called the Shoulder of the Knife by-Artifts. T H Handle of the crooked Knife is commonly of Ebony, fix Inches long, aind of a Bignefs requifite to fill the Hand, its Figure ought to be with eight Facets, not onlypfor an Ornament, but alfo to hold it faft: It muft end in its hinder Part with a Kind of Convolution, or rather an Eagle's Head, the Bill whereof flhall be turned on the Side of the Back of the Knife, to fcrvc as a flay to the Fingers of the Operator. THE firait Knife is' made Ufe of to cut the VFleih between the Bones of the Lceg, or fore Arm; but becaufe I have fufficicntly dclr-ibcd that Infirumcnt, I need not fay any Thing of it here. T H E Amputation Saw may be divided into three Parts: The moft material, is the Blade or' Saw, properly fo called; the fecond is the Arbor of the Saw, and the third is the Handle. T HE Blade of a Saw is elaftick, a Foot long, and two Inches broad, and made of a Piece of Steel forged cold, and confequently without of Chirurgical Inftruments. 581 Without being tempered, for the Reafons abovementioned, when I fpoke of the Coronets of the Trepan. The upper Part of that Saw is the Back, which ought to be very thin, and the lower is the Edge fet with many fmall Teeth, which alterniately projea outwardly, to make more Way for the Back of the Blade. But when the lower Part of the Blade is three Times thicker than the Bone, there is no need the fmall Teeth thould projea outwards. THE Arbor confifts of three Branches. One is placed horizontally, and in the parallel Line of the Blade; and the two others are perpendicular, and ferve to hold the two Ends of the Blade, viz. the foremoft, with the Help of a flat Screw, and the hinder one with a Screw that ferves to brace the Blade. The Handle of the Saw is like that of the crooked Knife. THE Inftruments proper to ftop the Blood, are the Needles, the 'Duck-bill'd Forceps, the Valet a 'Patin, &c. I have fufficiently defcribed them above. THUS I have at laft made an end of this Work. I fhall be very well rewarded, if young Scholars receive it with the fame Pleafure as I offer it to them, and if they reap any Benefit from it. FINIS. BOOKSprintedfor and fold by THo. WOODWARD, at the Half Moon over-againfl St. Dunflan's Church in Fleetftreet. I. EN ENE RAL Obfervations and approved G Prefcriptions in the modern Pradice Sof RPhyjick; containing the beft Method of curing moft Diftempers; amongft which, the Plague, the Gout, the Cholick, Confumption, Scurvy, Jaundice, Venereal Difeafe, Small Pox, and Meafles, Apoplexies, Palfies, Stoppage of Urine,*Afthma, Dropfy, Plcurify, &c. II. A Syllabus of what is to be performed in a Courfe of Anatomy, Chirurgical Operations and Bandages: By John Douglas, Surgeon.Price i s. 6d. III. 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U -di d / V 4 be 'V 'Vt * ~>t -~ //C~b-l ~~r * if 1L; e; r - I C u ~-S" e p _iii~~ r 18 i~ ~.~ * * \ 'Br ~~' r ~.ir r~ J ~~~. ~.I~~ ~~~-lir:-:;i-s i~ i J a,~ ' ~ ~: r ' "; 1 s.i ~ ~~~Yh: ct; ) ~;. 6- ~r;.r ' "; ri ~ "I ~ it. -~, ~,, _ i i~.~~,~ f~..I: ri.r ~;~ y.. 2 tr~Uur: r:: F cc B -":~;~~~t~r~~.:L:' r cr 17y'' ~F LK a.,.i ~ 2:,:~~ 4 ~e ' ~k ~ ~~ ~ilR i `:f i~ -; I C1 t;u i ~~ lr 9? t la8~t., s ~~ r ~ _ 1 k;- r~.,!:L ~ r i..*ik;i a r ~ 1`~ * r.. r -rr ~ ~ ~;'" L t ~:--~" L ~\ 'i t t ~i ~ ~- r f r; 8 "~ "' I-'~~ ~ 'S1 140~ 1 ~~ r j I F"s. i~i r.. h. J ll~e i- i:: ~i i F ~~ r a ~, rl I. I-: i~ ~ ~.~Z, t C L l;i:i b V i~ 1: a - ~ t ri~, ' 1 " ' *::: i 1. a i LdRlgA~I 9 - - i. r;: ~ ~~ i -t 'is,......:ai~ ~ Z-~J iJ , 4ý:Jp NO w Vi RAM S I I i w4