The Compleat Surgeon Part 33

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CHAP. XXI.

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

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

In order to cut off a Leg, the Patient is to be set on the side of his Bed, or in a Chair, and supported by divers a.s.sistants; one of 'em being employ'd to hold the Leg at the bottom, and another to draw the Skin upward above the Knee, to the end that the Flesh may cover the Bone again after the Operation. In the mean while a very thick Bolster is laid under the Ham, upon which are made two Ligatures, _viz._ the first above the Knee, to stop the Blood, by s.c.r.e.w.i.n.g it up with the _Tourniquet_ or _Gripe-Stick_; and the second below the Knee, to render the Flesh firm for the Knife.

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

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

_The Dressing and Bandage._

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

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

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

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

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

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CHAP. XXII.

_Of the Operation of the _Aneurism_._

This Operation is perform'd when the Surgeon hath p.r.i.c.kt an Artery, or when a Tumour ariseth in an Artery.

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

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

_The Bandage_

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

CHAP. XXIII.

_Of the Operation of _Phlebotomy_._

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

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

_The Bandage_

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

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

CHAP. XXIV.

_Of the Operation of _Encysted Tumours_._

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

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

_Of _Ganglions_._

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

CHAP. XXV.

_Of the Operation of the _Hydrocephalus_._

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

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CHAP. XXVI.

_Of the operation of cutting the Tongue-String._

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

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