bone and joint, and held back by an affiftant. Every artery which appears is now to be fecured. Then the capfular ligament, and next the round one, are to be feparated from the acetabulum; by which means the limb will be removed from the body. The acetabulum and neighbouring bone are next to be examined; and if they appear found, the cafe will be more favourable; but at any rate a cure is to be attempted by the firit intention. For which purpose, after removing all the clotted blood from the furface of the wound, and bringing the ligatures over the edges of the fkin, the mufcles are to be placed as nearly as poffible in their natural fituation; and drawing the flaps together, fo as to cover the wound in the most accurate manner, they are to be kept in this fituation by adhesive plafter, and by the twifted future and other dreflings, as in amputating at the under part of the thigh. The dreffings are to be retained by a broad flannel roller palled 3 or 4 times round the body, and spirally over the ftump, and fecured. The patient is then to be laid in bed on the found fiue, and treated as for amputation in other parts of the body; only that greater attention is neceffary, as there is no affiftance from a tourniquet. Uncommon attention will alfo be neceffary to prevent inflammation, and every symptom of fever which may fucceed to the operation. 824. When the foot is fo much diseased as to require amputation, the operation might be per. formed at the point of the ankle; but for the reafons given, when treating of amputation of the leg, it is found better to do it above the ankle, When a confiderable part remains found, it ought to be faved. If any of the tarfal bones are affect ed, these are to be removed. When the middle or whole body of any of the metatarsal bones are difeafed, they are to be removed in the fame manner as directed for fimilar operations in bones of the hand; and if even two of them remain found, provided they be fo placed as to fupport the toes, they ought to be preserved, as it is known that, by proper treatment, an offeous matter may af terwards hill a confiderable part, if not the whole of the void; or if any cavity remain, it may be fo ftuffed that the ufe of the foot may ftill be enjoyed. 825. In performing an operation of this kind, the patient thould be upon a table, and the tourniquet applied in the ham to prevent hemorrhagy, An incifion is then to be made along the affected part; and if the feat of the difeafe admit it, the incifion fhould be made upon the upper fide of the foot to as to fave the fole. The integuments are to be separated and turned to each fide, to allow the affected parts to be completely removed. 826. The principal veffels and nerves are to be faved as much as poffible, but if any particular artery be cut, it is to be fecured, and the part treated as after the removal of fimilar parts of the hand. when they protruded in fuch a manner that they could not otherwise be returned, have frequently been fawed through; and their place has trequently been fupplied by a renewal of bone, to as to preserve the ordinary use of the limb. Many cafes have likewife happened, where a large part of the body of the bone has been thrown out by fuppuration, and its place supplied; and a few are upon record, where either the whole of a bone, or that end next the joint, has been thrown out, and its place filled up with callus, fo that no inconvenience has been felt. From thefe circumftances, Mr White of Manchester was led to preferve an arm by fawing off the head of a diseased humerus; and Mr Park of Liverpool, to fave a limb, by fawing off the ends of the bones, in a cafe of white twelling of the knee. When therefore it happens that the end of a bone is diseased, while the other parts are found, the difeaied part may be removed, and the found one taved, fo as in a great meature to preserve the free ule of the limb. 829. In performing the operation, the firft ftep fhould be, to ufe fuch means as may enable the operator to have a full management of the circu lation of the part affected. Then a longitudinal incifion of fufficient length, and perhaps another acrois it, may be necefiary to be made through the foft parts of the joint; and this opening ought to be at a distance from the large blood-veffels, that they may be in no danger of being injured. After the end of the difeafed bone is sufficiently laid bare, it is either to be brought out of the joint, or a spatula or fome other proper fubftance is to be introduced between the bone and loft parts, fo as to defend the latter in time of fawing the bone. Atter the difeafed part of the bone is removed, the arterial branches are to be secured, and the wound treated like any other wound of equal fize. 830. During the cure the limb ought to be kept in the potture moft favourable for the removal of the bone, and afterwards for the preservation of the natural motion of the joint. In this way a limb may fometimes be laved which would otherwife have been removed. But though the removal of the dileafed end of one pone may be readily effected, the removal of all that part of the bones which enters into the compofition of a joint must be attended with fo much inconvenience, that it can feldom be useful, uniefs it be where the ends of bones are deftroyed by external violence; for then it appears that this operation may be performed with confiderable fuccefs. CHAP. XXXIV. OF DIMINISHING PAIN 18 SURGICAL OPERATIONS. 831. THE pain induced by furgical operations may be leffened in two different ways. The firft is by diminishing the natural fenfibility of the fyftem; and for this purpofe narcotics of different kinds, and particularly opium, have been used; but thefe are apt to induce difagreeable symptoms, cipecially ficknefs, and vomiting, which might be attended with bad confequences after fome operations. They are therefore feldom employed before an operation. When, however, 828. In compound fractures, the ends of bones, they are given immediately after it, and repeated 827. The amputation of the toes is exactly fimilar to that of the fingers. SECT. VI. Of REMOVING the ENDS of CARIOUS BONES in the JOINTS. as circumstances may require, they often give great relief. 832. The other method of diminishing pain is, by leffening the fenfibility of a particular part of the body. It has long been known, that the fenfibility of any part may not only be leffened, but entirely fufpended, by compreffing the nerves which fupply it. From a knowledge of this circumftance, an inftrument (Pl. CCCXXVIII. fig. 123.) was invented fome years ago by Mr James Moore of London, by which the principal nerves of a member might be fo compreffed as to render the parts below perfectly infenfible. A difficulty, however, arifes here; for as the nerves muft be, compreffed at leaft an hour previous to the operation, in order to render the parts quite infenfible, and as it is extremely difficult to comprefs the nerves without at the fame time affecting the veins, the latter are therefore in danger of being burft. To prevent this inconvenience, Mr Moore proposes to open a vein; but this might be attended with bad confequences in weakly conftitutions. Befides, it is faid, that by compreffing the nerves in this manner, although lefs pain may be felt in the time of the operation, it is proportionally greater after the compreffion is removed. In certain parts of the body, however, where fufficient compreffion can be made upon the nerves without acting much upon the veins, it would appear that the method may be practifed with advantage; though it has not yet been done, excepting in a few inftances. CHAP. XXXV. OF BANDAGES. 833. THE proper application of bandages is an object of great importance in furgery; and though dexterity is only to be acquired in this branch by practice, yet a few general rules may be useful. Bandages are employed for the retention of dreffings, for ftopping hemorrhagies, for removing deformities, and for effecting the union of divided parts. They ought to be formed of fuch materials as are fufficiently firm, while, at the fame time, they give no uneafinefs to the parts to which they are applied. They may be compofed either of linen, cotton, or flannel. Of late years the two laft have been preferred by many for their warmth and elafticity, on which account they are certainly the moft proper, efpecially in winter; and likewife in cafes where the parts are liable to fwelling and inflammation, as in wounds, luxations, and fractures. Befides, they more readily absorb any moisture which may be discharged from the fores. 834. When first applied, they should be clean, fufficiently ftrong, and as free of feams as poffible. They should be fo tightly applied as to answer the purpose for which they are intended, without being in danger of impeding the circulation. They fhould be applied in such a manner that they may be eafily loosened, and the parts examined with as much accuracy as poffible; and they should be laid afide as foon as the purpose for which they are intended is accomplished; for when longer continued, they frequently impede the growth of the parts upon which they are applied. 835. The couvre chef of the French, which is a fquare napkin folded cornerwise, is moft frequent ly ufed where a bandage is wanted for the head; but a nightcap, having a band to go round the head, and another to tie under the chin, appears to be more fuitable for this purpose. For making compreffion on any particular part of the head, as for ftopping of bleeding veffels, the radiated bandage may be employed. 836. For keeping the edges of wounds together, as in cafes of longitudinal cuts of the head, or of any other parts, the uniting bandage is ufually employed, and is always to be preferred to futures, where it retains the edges of the wound with fufficient exactness. For retaining dreffings upon the eyes, feveral turns of a roller have been ufed, and it is termed monoculus or binoculus according to its being applied to one or both eyes; but the couvre chef, and the nightcap already mentioned, are lefs apt to flip, and therefore found more convenient for this purpose. 837. For fractures of the nose, or wounds there, or on any other part of the face, the uniting ban. dage answers beft. And in cafes of fracture of the lower jaw, a four headed roller is moft convenient; the hole in the centre of the roller receives the chin, and affifts in preventing the bandage from shifting. The two upper heads are to be carried backwards; and being made to pals each other at the occiput, they are afterwards brought once or twice round the head. The two other heads of the roller being reflected over the chin, are then to be turned upwards and fixed on the upper part of the head. 838. The bandages neceffary for the neck are, the machine already mentioned after the operation of bronchotomy, and one ufed in cafes of wry neck. For every other purpose of bandaging a common roller may answer perfectly well. For fractures of the fcapula the application of a long roller may be of service. 839. For retaining dreffings upon the thorax, the napkin and fcapulary are commonly, and very properly used; and when the napkin is employed merely for retaining dreffings, it need not be longer than to pafs once round the body; but if it be used for making preffure over a fractured rib, it ought to pafs two or three times round. For both purposes its breadth ought to be 6 or 7 inches for an adult. 840. The fame kind of bandages is alfo ufed for making preffure on the abdomen, as in cafes of umbilical or ventral hernia; and to keep the bandage properly placed, a fcapulary is used for preventing it from flipping down, and one or two ftraps connected with it behind, are brought between the thighs, and fixed to it before to prevent it from moving up. A bandage of flannel, and different kinds of belts, are contrived for compreffing the abdomen in the operation of tapping; and truffes of various conftructions are used for the retention of the protruded bowels in cafes of hernia. 841. Bandages of cotton or flannel are used for fupporting the fcrotum in the various diseases which may occur there, as well as after the operations performed upon it. One of the best bandages for the penis is a linen or cotton bag, fixed by a roller round the body. For retaining dreffings about the anus, or between that part and the 1 720 SURGERY. the ferotum, the T bandage is commonly used; and it is made either with one or two tails, according to the fituation of the part to which it is to be applied. 842. In timple fractures, and most of the other difeafes of the arm, fore-arm, and hand, the roller is the bandage commonly ufed, but in compound fractures of these parts, as well as in the different kinds of fractures of the lower extremities, the 12 or 18-tailed bandage is neceffary. 843. For longitudinal wounds of the extremities, the uniting bandage is ufed with the fame advantage as has been already mentioned for wounds of a fimilar nature upon the head. CHAP. XXXVI. OF THE METHOD OF O. PENING A DEAD BODY., 844. SURGEONS are often called to inveftigate the cause and feat of difeafes and death, either by the relations of the difeafed, or the magiftates to whom a report is to be made; therefore, at the time of performing this operation, minutes fhould be taken of what is obferved. The inftruments, and all things neceffary, fhould be difpofed in order, as for any other operation; as knives, a razor, a great and small faw, fciffars ftraight and curved, elevators, needles threaded, fponges, tow, faw-duft or bran, bafons with water, towels, and receivers for the vifcera when they are to be taken out of their cavities. The body is to be laid upon a fuitable table, advantageously placed for the light, having a cloth thrown over the parts which decency demands fhould be concealed, efpecially in females. 845. When it is intended only to infpect the abdomen and its contents, a longitudinal incifion from the xiphoid cartilage to the os pubis, interfected by a tranfverfe one at the navel, will give a fair opportunity of anfwering thefe purposes, when the angles are reverfed. Should it be required to examine all the three cavities, and the parts contained in them, we are to begin by opening the head, making an incifion quite cross to the bone, from ear to ear; which fection is preferable to the crucial commonly made on this occafion; then the fcalp may be easily diffected from the skull, and turned down over the face, and towards the neck, giving room for the faw. The head must be held very fteadily by an afliftant during the fawing, which fhould be begun on the middle of the frontal, proceeding to each temporal bone, and fo to finish the circle upon the middle of the occipital bone; which may generally be done conveniently enough, by raifing the head and inclining it forward, after having proceeded as far as this bone; or the body may then be turned prone, fhould that pofture be found more convenient to complete the circle. The cap of the skull is then to be raised with the clevator, occafionally cutting the adhefions of the dura mater; after this the encephalon is to be removed, carefully feparating the other attach ments of the membrane. 846. To bring the thorax and abdomen, with the parts contained in thefe cavities, under one view, an incifion is to be made on each fide of the fternum, in the courfe of the cartilages of the ribs which are annexed to it; diffecting from 1 thence the mufcles with the teguments, the space CHAP. XXXVII. of two or three inches towards the fpine; then cutting through the cartilages, which will be ved near the point; then the incifions are to be feen, and easily divided with a knife a little curcontinued from the fternum through the abdominal cavity, in an oblique direction, to each ilium or inguen; after which the clavicles are to be feparated from the fternum, or this bone divided knife, diffecting it from the mediaftinum, and at its fuperior cartilaginous junction, with a strong turning it downwards with the mufcles, &c. of the abdomen. This is the most eligible manner of opening thefe cavities, and gives an opportunity of fewing them up with a better appearance any perfon's view afterwards. That kind of feam has a very pretty and neat effect upon thefe ftitch called by fempftreffes the herring bone or fiat occafions. for and abdominal vifcera together, for further exa847. If it is propofed to take out the thoracic mination, the diaphragm is firft to be cut down to the fpine on both fides; then, to avoid being incommoded with blood, &c. two very firong ligatures are to be paffed round the fophagus and large blood veffels, in which the trachea may be included; tying them ftrait, and then dividing thefe parts between the ligatures; the fame meafures are to be taken in refpect to the inferior veffels upon the lumbar region, a little above the bifurcation of the acrta, including the vena cava ; and alfo upon the rectum. After having obferved thefe precautions, the vifcera, with the diaphragm, way clofe to the fpine; and by gently drawing are to be removed by a wary diffection, all the them at the fame time, the feparation will be greatly facilitated. are to be taken out feparately, in the first cafe li848. When the thoracic and abdominal vifcera upon the veels, &c. juft above the diaphragm, gatures must be made, as have been defcribed and in the other just below it, and upon the rec tum. 849. If called upon to perform this office when lutely neceffary to have fuch parts of it well washthe body is become very putrid, it will be abfoed with warm vinegar and brandy, and then fprinkled with lavender water, or fome fuch odoriferous antiputrefcent liquor, before the examination, in order to correct the teach, and defend us againft the noxious quality of the effluvia; a precaution, the neglect of which may be attended with very direful eftects, CHAP. XXXVII. OF EMBALMING DEAD tice of embalming dead bodies was very common, opening a dead body, and containing the incifion 851. After evifceration, as has been directed in farther upwards, even into the mouth, and, if practicable, practicable, without cutting the fkin of the neck, 852. After the application of the cerecloth, ABDOMEN, WOunds of the, 36 -39; 65-67; paracentefis Ægineta, Paulus, an aminent furgeon, 15. Actius, his furgical works, 15. fing them well everywhere, the face, being clofe INDEX. 799; method of performing 449-451, 453. tem of surgery, 21; his screw, Arabia, hiftory of furgery in, Arm, luxations of the bones of Arfenic, prescribed for cancer, Arteries, wounds of, 32; futures Arteriotomy feldom practifed, Atheromatous tumours, 192. B Bandages, prescribed by Hippo- 22. Bell, Mr Benj. his formula of Benign Node, 277. : Cancers, different fpecies of, 161 : DAVIEL's method of treating ca- Dead bodies, method of open- ing, 844-849: of embalming, Deafnefs, causes of, 503-507: Derangement of teeth, 476, 477. Dran, Le, quoted, 154. 828-830. Botallus, L. a writer on gun- Brain, affections of the, from Canula, ufed in bronchotomy, Carious ulcers, 125, 136, 137: Carpus, J. an early surgical au- thor, 21. Cartilaginous concretions in the Cataract, 432: treatment of the, Dropfical fwellings of the joints, 433-441. Catheters, 685. 128. Cauteries, much used among the Arabs, 17. Celfus, an account of his furgi- 200-202. Droply, 529, 530: operation E Ear, diseases of the, and opera- |