The Compleat Surgeon Part 29

_What is a _Rhombus_?_

It is a small Tumour of the Blood which happens in the place where the Operation is perform'd either by making the Orifice too small, or larger than the Capaciousness of the Vessel will admit. The _Rhombus_ is cur'd by laying upon it a Bolster dipt in fair Water, between the Folds of which must be put a little Salt, to dissolve and prevent the Suppuration.

_How may it be perceiv'd that an Artery hath been p.r.i.c.kt or open'd in letting Blood?_

The Puncture of an Artery produceth an Aneurism; and the Opening of it causeth a Flux of Vermilion Colour'd Blood, which issueth forth in abundance, and by Leaps.

_Are the Leaps which the Blood makes in running, a certain Sign that it comes from an Artery?_

No, because it may so happen, that the _Basilick_ Vein lies directly upon an Artery, the beating of which may cause the Blood of the {206} _Basilica_ to run out leaping: Therefore these three Circ.u.mstances ought to be consider'd jointly, that is to say, the Vermilion Colour, the great quant.i.ty and the Leaps, in order to be a.s.sur'd that the Blood proceeds from an Artery.

_How may it be discover'd that a Tendon hath been hurt in letting Blood?_

It is known when in opening the _Median_ Vein, the end of the Lancet hath met with some Resistance; when the Patient hath felt great Pain, and afterward when the Tendon apparently begins to be puff'd up, and the Arm to swell. A Remedy may be apply'd to this Accident thus; after having finish'd the Operation, a Bolster steep'd in _Oxycratum_ is to be laid upon the Vessel, a proper Bandage is to be made, and the Arm must be wrapt up in a Scarf: If the Inflammation that ariseth in the Part be follow'd with Suppuration, it must be dress'd with a small Tent; and if the Suppuration be considerable, it is necessary to dilate the Wound, and to make use of Oil of Eggs and Brandy, or _Arcaeus_'s Liniment, with a good Digestive; as also to apply _Emplastrum Ceratum_; to make an Embrocation on the Arm with Oil of Roses; and to dip the Bolsters in _Oxycratum_ to cover the whole Part.

_Is it not to be fear'd that some Nerve may be wounded in letting Blood?_

No, they lie so deep that they cannot be touch'd.

_Under what Vein is the Artery of the Arm?_

It is usually situated under the _Basilica_. {207}

_What Course is proper to be taken to avoid the Puncture of an Artery in letting Blood?_

It must be felt with the Hand before the Ligature is made, observing well whether it be deep or superficial; for when it lies deep, there is nothing to be fear'd; and when it is superficial, it may be easily avoided by p.r.i.c.king the Vein either higher or lower.

_What is to be done when an Artery is open'd?_

If it be well open'd, it is requisite to let the Blood run out till the Person falls into a _Syncope_ or Swoon, by which means the Aneurism is prevented; and afterward the Blood will be more easily stopt: It remains only to make a good Bandage with many Bolsters, in the first of which is simply put a Counter or a Piece of Money; but a bit of Paper chew'd will serve much better, with Bolsters laid upon it in several Folds.

_If the Arteries cause so much trouble when open'd accidentally, why are those of the Temples sometimes open'd on purpose, to a.s.swage violent Pains in the Head?_

By reason that in this place the Arteries are situated upon the Bones that press 'em behind; which very much facilitates their re-union.

_Are not the Arteries of Persons advanc'd in Years more difficult to be clos'd than those of Children?_

Yes. {208}

_Are there not Accidents to be fear'd in letting Blood in the Foot?_

Much less than in the Arm; because the Veins of the _Malleoli_ or Ankles are not accompany'd either with Arteries or Tendons; which gave occasion to the Saying, _That the Arm must be given to be let Blood only to an able Surgeon, but the Foot may be afforded to a young Pract.i.tioner_.

{209}

A

TREATISE

OF

_Chirurgical Operations_.

CHAP. I.

_Of the Operation of the Trepan._

This Operation is to be perform'd, when it is inferr'd from the Signs of which we have already given a particular Account, that some Matter is diffus'd over the _Dura Mater_. The Trepan must not be us'd in the _Sinus Superciliares_, by reason of their Cavity; nor in the Sutures, in regard of the Vessels that pa.s.s thro' 'em; nor in the Temporal Bone without great necessity, especially in that part of it which is join'd to the Parietal-Bone, lest the end of this Bone shou'd fly out of its place, since it is only laid upon the Parietal; nor in the middle of the Coronal and Occipital-Bones, by reason of an inner {210} Prominence wherein they adhere to the _Dura Mater_; nor in the Pa.s.sage of the Lateral _Sinus's_ that are situated on the side of the Occipital.

If the Fissure be very small, the Trepan may be apply'd upon it, altho' it is more expedient to use this Instrument on the side of the Fissure in the lower part; neither is the Trepan to be set upon the Sinkings; and if the Bones are loosen'd or separated, there needs no other trepanning than to take 'em away with the Elevatory.

The Operation must be begun with Incision, which is usually made in form of a Cross, if the Wound be remote from the Sutures, and there are no Muscles to be cut, and in the shape of the Letter T. or of the Figure 7. if it be near the Sutures, so that the Foot of the 7. or of the T. ought to be parallel to the Suture, the top of the Letter descending toward the Temples; it is also made in the middle of the Forehead. If it be sufficient to make a longitudinal Incision in the Forehead; its Wrinkles may be follow'd, and there will be less Deformity in the Scar; but it is never done Crosswise in this Part, and the Lips of the Wound are not to be cut.

If an Incision be made on the Muscle _Crotaphites_, and on those of the back-part of the Head, it may be done in form of the Letter V. the Point of which will stand at the bottom of the Muscles; nevertheless it is more convenient to make a longitudinal Incision, by which means fewer Fibres will be cut; and it is always requisite to begin at the lower part, to avoid being hindred by the Haemorrhage. {211} The Incisions are to be made with the Incision-Knife, and that too boldly when there are no Sinkings; but if there be any, too much weight must not be laid upon 'em: Thus the Incision being finish'd, the Lips of the Skull are to be separated either with the Fingers, or some convenient Instrument; Then if there be no urgent Occasion to apply the Trepan, it may be deferr'd till the next Day, the Wound being dress'd in the mean time with Plaisters, Bolsters, Pledgets, and a large Kerchief or upper Dressing, the use of which we shall shew hereafter.

The Operation is begun with the Perforative, to make a little Hole for the fixing of the Pyramid or Pin which is in the Round; afterward the Round is to be apply'd, holding the Handle of the Trepan with the Left-hand, and turning with the other very fast in the beginning; but when the Round hath made its way, it is lifted up to remove the Pin, lest this Point shou'd hurt the _Dura Mater_: Thus the Round being taken off from time to time, to be cleans'd from the Filings that stick thereto, is set on again, and the Operator begins his Work of turning anew, which must be carry'd on gently when any Blood appears, to the end that the first Table of the piece of Bone which is remov'd may not fly from the second: When it comes near the _Dura Mater_, the Operator must proceed, in like manner, gently, searching with a Feather round about the Bone, to observe whether he still continueth his Course in the Skull. He must also often lift up the Trepan to search the Hole, to cleanse the Instrument, and to keep {212} it from growing hot.

As often as the Trepan is taken off, let him search with a Feather, to see whether the Bone be cut equally; and if it be not, he must lean more on that side which is least cut. If it be necessary to make use of the _Terebella_, the Hole must be made in the beginning, whilst the Bone is as yet firm; and when the Piece begins to move, the _Terebella_ is to be put very gently into its Hole, without pressing the Bone, to draw it out; or else it may be taken away with the Myrtle-Leaf, which is an Instrument made of a firm Silver-Plate somewhat crooked. When the Piece is thus remov'd, the uneven Parts that remain at the bottom of the Hole, are to be cut with the _Lenticula_; and if there be any Sinkings, they may be rais'd with the Elevatory. Whereupon the _Dura Mater_ may be compress'd a little with the _Lenticula_, to facilitate the running out of the Blood, the Wounded Person being oblig'd to stoop with his Head downward, stopping his Nose and Mouth, and holding his Breath for a while, to cause the Matter to run out: Then the _Dura Mater_ may be wip'd with Lint; but if any _Pus_ or corrupt Matter lies underneath, it must be pierc'd with a Lancet wrapt up in a Tent, that it may not be perceiv'd by the a.s.sistants. Afterward a _Sindon_ or very fine Linnen Rag dipt in a proper Medicament, is put between the _Dura Mater_ and the Skull; the Hole is fill'd with small Bolsters steept in convenient Medicinal Liquors; and the Wound is dress'd with Pledgets, a Plaister, and a Kerchief. {213}

But the Hole ought to be well stopt with Bolsters, because the _Dura Mater_ is sometimes so much inflam'd, that it bursts forth; so that if any Excrescences arise therein, and go out of the Hole, having small Roots, they may be bound and cut; but if their Roots be large, they must be press'd close with little Bolsters steept in Spirituous Medicines. Here it may not be improper to observe, that the Operation of the Trepan ought to be perform'd more gently in Children than in adult Persons, in regard that their Bones are more tender, and that Oily Medicines must not be us'd, but Spirituous. The Exfoliation is made sometimes sooner, and sometimes later; but the _Callus_ usually covers the opening of the Skull within the s.p.a.ce of forty or fifty Days, if no ill Accident happens. In great Fractures, where there is no longer any connexion between the Bones, it is requisite to take 'em away.

_Of the Bandage of the Trepan._

The proper Bandage to be us'd after the Operation of the Trepan, is the great Kerchief, which is a large Napkin folded into two parts after such a manner that the side which toucheth the Head exceeds that which doth not touch it in the breadth of four Fingers; it is apply'd to the Head in the middle, whilst a Servant holds the Dressing with his Hand: Then the two upper ends of the Napkin being brought under Chin, the Surgeon takes the two lower, and draws 'em streight by the sides, so as that side the Napkin, which is four Fingers broader {214} than the other, may be laid upon the Forehead: Afterward the two ends of the Napkin are cross'd behind the Head, and fasten'd at their Extremities with Pins, without making any Folds, that might hurt the Part; but the ends of the Napkin which fall upon the Shoulders, are rais'd up to the Head near the lesser Corner of the Eyes; and the two ends under the Chin are fasten'd with Pins, or else tied in a Knot.

CHAP. II.

_Of the Operation of the _Fistula Lachrymalis_._

This Operation is perform'd when there is a Fistulous Ulcer in the great Corner of the Eye, after this manner: The Patient being plac'd in a convenient Posture, and having his sound Eye bound up, to take away the sight of the Instruments; the Operator causeth the other Eye to be kept steady with a Bolster held with an Instrument, and makes an Incision with a Lancet in form of a Crescent upon the Tumour, taking care to avoid cutting the Eye-Lid and the little Cartilage which serves as a Pulley to the great Oblique Muscle. If the Bone be putrify'd with a _Caries_, an Actual Cautery may be apply'd thereto, using for that purpose a small Funnel or Tube, thro' the Ca.n.a.l of which the Cautery is convey'd to the Bone. {215} But the Bone must not be pierc'd, for it is exfoliated entire by reason of its smallness; and so the Hole is made without any Perforation.

_The Dressing and Bandage of the _Fistula Lachrymalis_._

The Wound is fill'd with small dry Pledgets, and cover'd with a Plaister and Bolster: The Bandage is made with an Handkerchief folded triangular-wise, the ends of which are fasten'd behind the Head. If the Flesh grows too fast, it may be consum'd with the _Lapis Infernalis_; and if there be occasion to dilate the Wound, to facilitate the Exfoliation, it may be done with little pieces of Spunge prepar'd, and put into it.

Afterward Causticks are to be us'd, to eat away the Callous Parts, which may be mingled with Oily Medicines, to weaken their Action, taking care, nevertheless, that the Eye receive no dammage by 'em. If the Bone be corrupted, a little _Euphorbium_ may be apply'd; or else the small Pledgets steept in the Tincture of Myrrh and Aloes; then the Ulcer may be handled as all others.

{216}