The Compleat Surgeon Part 31

_The Dressing._

The Wound is to be dress'd with Pledgets strew'd with Astringent Powders, a Plaister, a Bolster, a Napkin round the Brest, and a Scapulary to support the whole Bandage. {226}

But instead of pa.s.sing Threads cross-wise, to form a Handle, with which the Breast may be taken off, it wou'd be more expedient to make use of a sort of _Forceps_ turn'd at both ends in form of a Crescent, after such a manner that those ends may fall one upon another when the _Forceps_ are shut. Thus the Surgeon may lay hold on the Breast with these _Forceps_, and draw it off, after having cut it at one single Stroak with a very flat, crooked, and sharp Knife. Neither is it convenient to apply the Actual Cautery to stop the Haemorrhage, because it is apt to break forth again anew, when the Escar is fall'n off,

When the Tumour is not as yet ulcerated, a Crucial Incision may be made in the Skin, without penetrating into the Glandulous Bodies; then the four Pieces of the Glandules being separated, the Cancerous Tumour may be held with the _Forceps_, and afterward cut off. If there be any Vessels swell'd, they may be bound before the Tumour is taken away; but if the Tumour sticks close to the Ribs, the Operation is not usually undertaken.

{227}

CHAP. IX.

_Of the Operation of the _Empyema_._

This Operation is perform'd when it may be reasonably concluded that some corrupt Matter is lodg'd in the Breast, which may be perceiv'd by the weight that the Patient feels in fetching his Breath; being also sensible of the floating of the Matter when he turns himself from one side to another.

If the Tumour appears on the outside, the Abcess may be open'd between the Ribs; but if no external Signs are discern'd, the Surgeon may choose a more convenient place to make the Opening. Thus when the Patient is set upon his Bed, and conveniently supported, the Opening is to be made between the second and third of the Spurious Ribs, within four Fingers breadth of the Spine, and the lower Corner of the _Omoplata_; to this purpose the Skin is to be taken up a-cross, to cut it in its length, the Surgeon holding it on one side, and the a.s.sistant on the other. The Incision is made with a streight Knife two or three Fingers breadth long, and the Fibres of the great Dorsal-Muscle are cut a-cross, that they may not stop the Opening.

Then the Surgeon puts the Fore-Finger of his Left-hand into the Incision, to remove the Fibres, and divides the Intercostal Muscles, guiding the Point of the Knife with his Finger to pierce the _Pleuron_, for fear of wounding {228} the Lungs, which sometimes adhere thereto, the Opening being thus finish'd, if the Matter runs well, it must be taken out; but if not, the Fore-Finger must be put into the Wound, to disjoyn those Parts of the Lungs that stick to the _Pleuron_.

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

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

_The Dressing and Bandage._

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

CHAP. X.

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

This Manual Operation is sometimes necessary in a Dropsie, when Watry Humours are contain'd in the Cavity of the Belly, or else between the Teguments. The Disease is manifest by the great Swelling; and the Operation is perform'd with a Cane, or a Pipe made of Silver or Steel, with a sharp Stilet at the end; altho' the Ancients were wont to do it with a Lancet.

The Patient being supported, sitting on a Bed, or in a great Elbow-Chair, to the end that the Water may run downward, {230} a Servant must press the Belly with his Hands, that the Tumour may be extended, whilst the Surgeon perforates it three or four Fingers breadth below the Navel, and makes the Puncture on the side, to avoid the White-Line; but before the Opening is made, it is expedient that the Skin be a little lifted up. The pointed Stilet being accompany'd with its Pipe, remains in the Part after the Puncture; but it is remov'd to let out the Water; and a convenient quant.i.ty of it is taken away, accordingly as the Strength of the Patient will admit.

The Stilet makes so small an Opening, that it is not to be fear'd lest the Water shou'd run out, which might happen in making use of the Lancet, because there wou'd be occasion for a thicker Pipe. When a new Puncture is requisite, it must be begun beneath the former; but if the Waters cause the Navel to stand out, the Opening may be made therein, without seeking for any other place.

_The Bandage and Dressing_

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

_The Operation of the _Paracentesis_ of the _s.c.r.o.t.u.m__

Is undertaken when those Parts are full of Water, after this manner: a.s.soon as the Patient is plac'd in a convenient Posture, either {231} standing or sitting, the Operator lays hold on the _s.c.r.o.t.u.m_ with one Hand, presseth it a little to render the Tumour hard, and makes a Puncture, as in the _Paracentesis_ of the _Abdomen_. In an _Hydrocele_ that happens to young Infants, the Opening may be made with a Lancet, to take away all the Water at once: But in Men, especially when there is a great quant.i.ty thereof, it is more expedient to do it with the sharp-pointed Pipe; but the t.e.s.t.i.c.l.es are to be drawn back, for fear of wounding 'em with the Point of the Instrument.

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

When the Puncture is made, it ought to be done in the upper-part of the _s.c.r.o.t.u.m_, because it is less painful than the lower, and less subject to Inflammation.

CHAP XI.

_Of the Operation of _Gastroraphy_._

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

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

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

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

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

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

CHAP. XII.

_Of the Operation of the _Exomphalus_._

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

{236}

CHAP. XIII.

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

When the Intestinal Parts are fall'n into the Groin or the _s.c.r.o.t.u.m_, the Operation of the _Bubonocele_ may be conveniently perform'd; to which purpose the Patient is to be laid upon his Back, with his b.u.t.tocks somewhat high; then the Skin being grip'd a-cross the Tumour, the Surgeon holds it on one side, and the a.s.sistant on the other, till he makes an Incision, following the Folds or Wrinkles of the Groin; when the Fat appears, it is requisite to tear off either with a Fleam or even with the Nails, every thing that lies in the way, till the Intestine be laid open, which must be drawn out a little, to see if it do not cleave to the Rings of the Muscles.

The Intestine must be gently handl'd, to dissolve the Excrements; and those Parts must be afterward put up again into the Belly (if it be possible) with the two Fore-Fingers, thrusting 'em alternatively; but if they cannot be reduc'd, the Wound is to be dilated upward, by introducing a channell'd Probe into the Belly, to let the Sizzers into its Channelling. If the Probe cannot enter, the Intestine must be taken out a little, laying a Finger upon it near the Ring, and making a small Scarification in the Ring, with a streight Incision-Knife guided with the {237} Finger, to let in the Probe, into which may be put a crooked Knife, to cut the Ring; that is to say, to dilate the Wound on the inside; but care must be had to avoid penetrating too far, for fear of dividing a Branch of Arteries; and then the Parts may be put up into the Belly. If the Caul had caus'd the Rupture, it wou'd be requisite to bind it, and to cut off whatsoever is corrupted, scarifying the Ring on the inside, to make a good Cicatrice or Scar.

_The Dressing and Bandage._

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

_Of the compleat _Hernia_ or Rupture._