CAP. I. Of Operations in General.

AMong all the Parts of Medi­cine, there is none so profi­table as this which I under­take to treat of.VVhat it teaches. It teaches us how we ought to perform the O­perations of Surgery, it explains the chief Pathologic Phaenomena, for­tifies us in the knowledge of the Sub­ject, [Page 2]on which we practice? and I dare boldly say, that without the assistance of these Operations, the Art of Surgery would never have arrived to so high a point of perfection, which at this time it has atain'd; and without it, the Knowledge which relates to the ex­plication of the Principal Distempers,The Excel­lency of Chyrurgical Operations. would have been only dubious and uncertain, if light were not borrowed from hence by evident Demonstrati­ons, and by reasons which experience authorises. It's a study which con­tains nothing but what's worthy to entertain our Wits, and engages those who love the Profession, to shew the advantages we receive from it. It's this which recommends the Artist, who dexterously reunites the Parts divided, who divides those discreetly that are united, who draws together with an extraordinary care, those bo­dies which in respect one to another are strange, and who with Art and Industry supplies whatever are want­ing to our perfection, whence the end which he ought to propose to himself, is to perform well these four Operati­ons, to disentangle all the difficulties they contain, and to observe all the [Page 3]circumstances which are precedent, concomitant, and which follow, in order to maintain the parts in their union and natural Situation.

Here I have a large Field to dilate my-self into the praises of Surgery; but (besides that the shortness of time does not permit me) I must acknow­ledge I dare not undertake it, least I should sink under the weight of so painful an enterprize; for all the Au­thors, who have wrote of it, and boasted of their Excellency in this Art, were never able to give it those due Encomiums which are propor­tionable to the great advantages we find in it: wherefore I shall stick close to my Subject, and I dare say that if these new Anatomists, who have made such great and wonderful discoveries, had made a due and just application of them to the Art of Surgery, and if those great Practiti­oners, had enrich'd it with their Ob­servations, we should have found such advantages, which will never be un­less they change their Principles: But the Subject being so thorny and difficult, we find very few, who are willing to cummunicate to us their [Page 4]Ideas, and particular Discoveries. Most do but treat of these matters superficially, and without diving in­to the bottom, which is the reason that oft-times we cast the difficulty of the Art, upon the evil disposition of the subject: I acknowledge that it's very hard to hit always right, be­cause Nature is often various in her motions, and works in such hidden corners, and by ways so little known, that she destroys by some unexpected stroke (which we do not foresee) the whole Oeconomy of her Operati­ons.

It's not e­nough to understand the practice of Chirurgi­cal Opera­tions by halves.It's not sufficient to undertake one Operation only, we must have a perfect knowledge of the subject on which we are to exercise our Pra­ctice, that is to say, its Temper, Disposition, and the Part afflicted.

By the temper, I mean a certain disposition of parts, that consists in the order of these resorts or springs which compose them,VVhat the Tempers. and in the fi­gure of their Pores, proportionable to the nature of those liquors which pass thro' them, and of their motion, sometimes more, sometimes less rapid.

Disposition of the Body.The disposition of our bodies re­lates to the regimen of life, Inclina­tion, Age, Season, Habit, and Strength; for if an indisposed per­son observe an irregular way of li­ving, if he be of a spare body, void of strength, if his age obstruct the per­formance of the Operation, or in fine if he has a greater tendency to that which is contrary and hurtful to him, than to what will be profitable and advantageous, in this case the Sur­geon ought to suspend his Judgment, least he should run the risque of do­ing the indispos'd person more harm than good.

Part affe­cted.Touching the part which suffers, the Operator must perfectly under­stand its natural Constitution, Con­nection, Action, and Use, in case he designs to draw any advantage from his Undertakings, and prevent the emergent Symptoms usual in these occasions. If the Operation may be delayed, 'tis convenient to expect a favourable Season, as for example, the Spring and Autumn.

Nature of the Spring.In the Spring the Blood and Spi­rits (which the cold had driven to­wards the Centre) exalt themselves [Page 6]to the Surface, and with a greater heat revive the parts which before were as if benum'd, and without life, they are in a Fermentation, soft, natural, and by consequence capable of all the good effects which can be ex­pected.

But on the contrary in Winter the cold obstructs the Pores, hinders Transpiration, changes the Oecono­my of the Circulation, and the Blood is depriv'd of that vivacity which is capable to animate our bodies.

Nature of the AutumnIn the Autumn, the Action of the Salt and Sulphur which had seized the upper Parts, and which were in a continual exaltation (during the excessive heat of Summer) is a lit­tle represt; the Blood (which had got a sharp and bilious disposition, by an immoderate heat) sweetens and al­lays the extraordinary Effervescence, which was the occasion of a continu­al loss of Spirits.

These are (as I conceive) the chief Maxims which are to be observed before we enter upon the particular of every Operation.

I could enlarge my self more upon the Operations in general, but as [Page 7]such long discourses don't clear the difficulties which they contain, and according to the Order which I have proposed my self, to publish nothing to the World, which is not worthy the attention of the Reader, I con­ceived I might be excused from pro­ducing the troublesome Definitions, Divisions, and Subdivisions, which make up the Principal Ornament of the greatest part of Chyrurgical Au­thors.

CHAP. II. Of the Reunion of Wounds.

ACcording to the order of this Treatise, we begin with the Sutures, which are only practis'd to reunite the divided Parts, but first we must say something concerning Reunion; to be inform'd after what manner its done, we must observe two things.

Ʋnition of Parts divi­ded the work of Nature.The first is, that the Reunion of the divided Parts is only the Work of Nature, who on this occasion makes use of her natural Balm.

The second, That all the Surgeons Art doth nothing for this Reunion, but as he is the imitator of Nature, he must, to second her designs, and to procure the Union of Wounds, use three means.Three Means to be us'd towards the Ʋnition of wounds.

• First, To cleanse the Wounds exactly, and free them from all extraneous bodies.
• Second, To bring the Lips together, and
• Third, To keep them in the same situation; for to satisfie these three Intentions, a Surgeon must be in­form'd of the Structure of the Parts, and of the Nature of the nourishing Juyces which entertain them.

The Body on­ly a heap of Fibres, Ve­sicles and Vessels.As for the first, its necessary to know that all the parts of our body, are only a heap of Fibres, Vesicle;, and Vessels; but because the different ranks they keep disposes in every one of them Spaces and Pores of different figures, the nourishing Particles of Blood must needs accommodate them­selves differently, according to the various configurations of the Pores, and Conduits through which they pass.

Blood the common matter of nourish­ment, yet not the red part, but white.In consideration of the nourishing Juyce, one must imagine that the Blood which is the common mat­ter [Page 9]of it, contains and homogene­ous liquor, and though it appears to our eyes under the form of two sub­stances, notwithstanding it's certain that all the parts are nourished by its white and chilous part, and not at all by the red, if we conceive that this white part is sweet, balsamick, glewy, and viscous, which are all the requisite and necessary conditions for their entertaiment; from whence we may conclude that its the Balsam, and true Cement of all the Reunions which are made in Nature.

It would be hard to understand how this nourishing Juyce whose sub­stance is Homogeneal, can be em­ploy'd to the maintaining so great a number of different parts, if by what we have said of their Structure, we did not conceive that this juyce tho' indifferent, can easily become Flesh, an Artery, Membrane, Bone, Tendon, &c. according as its mo­dified passing thro' the insensible Chanels (which must be regarded as so many little threads) where it's shap'd and fram'd differently accor­ding to the Configuration of their Porosities; just as the parts of the [Page 10]sap, which are confounded, and as it were indeterminated in the earth, take a form and determinate figure on them, passing through the different Pores of the Fibres which compose the Plants, as round, pointed, square, &c. this diversity of Figures is the cause that those Par­ticles can produce quite contrary Ef­fects, as well in Plants as in Animals.

This being suppos'd and well un­derstood, I say that the Surgeons Sci­ence (whether in the Reunion, in losses of substance, or finally in what occasion soever) serves for nothing but to Rectifie this Sap, by the way of general Medicines (when 'tis corrupted;) and Topics, which have the vertue of conserving the na­tural Purity of the nourishing Juyce, which the Arteries carry to the of­fended Part, and to defend it in the same time from the impressions of the Air; therefore the Traumaticks, Sar­coticks, Carminatives, and Astrin­gents, which Surgeons use in the be­ginning, Progress, State, and declina­tion of wounds do produce such effects as I shall prove in explaining their vertues.

The Virtues of Trauma­tick Medi­cines.Vulneraries are ordinarily charg'd with oily and salt Particles, which cause two good effects.

• First, The oily Particles unite and adjust them­selves easily to the viscous, and nou­rishing Particles of the blood, and make together a kind of covert which resists the powerful attacks of the Air, which is a great enemy to Wounds.
• Secondly, The saline Particles divide, cut, and attenuate such parts which are most disposed to alteration, and help them forwards in suppuration.

Sarcoticks and Carmi­natives.The Sarcoticks and Carminatives (which only differ secundum majus & minus) do always abound in fine saltish Sulphur, and fixt disicative alcalies; the saltish and most rarified Sulphur subtilizes and purifies the nourishing Particles, and maintains them in their natural Motion, and consequently in their state of good­ness; whilst the fixt Alcalies, and other desicative Particles repel by a sort of caustick vertue, the most sharp and malign Particles capa­ble of producing a bad pus, and be­getting fungous flesh: the most exal­ted sharp Particles being absorbed, [Page 12]the flesh keeps united firm and red.

Of Astrin­gents.Concerning Astringent Remedies, 'tis proper to give a reason why Scars oftentimes are so deformed; this de­pends almost commonly on the Sur­geon, either because he has not-skill enough to make the Fibres answer one another; or else he compresses the Wound too rudely in searching for the strange Bodies, or because he sinks the Fibres of the Parts, (of which some tend upwards, other downwards) in their intercussading one another,Too Astrin­gents make Scars de­formed. so that the two lips of the wound, can never be exactly even; or finally because he makes use of too Astringent Remedies; all these contribute to make the Ci­catrix defective, but particularly Styptick Medicines, because being filled with fixt Alcaline, or Vitrio­lick Particles, the fixt ones stop the Pores, and the Vitriolick burn and cauterize them, and take away even some of the substance: This in ge­neral is the Idea one must have of the effect of these Medicines.

I pass now to the Reunion of the Tendons, which the Ancients and most part of our Moderns had [Page 13]abandoned, and which in imitation of them would have been neglected, if late Mr. BIENAISE (to who we are obliged for it) had not renew'd it.Sutures of the Tendons to be pra­ctised. In effect there's no more danger in practising the Suture of a Tendon than in that of a flesh wound; if we consider that the Liquor which runs into its Channels, is no way differing from that which passes into the Belly of the Muscle, why should it not be allow'd that the cut Tendon unites as well together as a Muscle? and since the same juyce runs into the Bones, to serve them for their nourishment, and is the true bond, and cement which reunites them when broke, why will not they al­low that it should produce the same effects in respect of the Tendons which are continuous to them? Don't we even observe in Plants when we put the Graff on a wild Stock,A parale [...] Comparison. that the Sap passes from the Porosities of the Longitudinal Fibres of the Stock to those of the Graff, that its salfish and glewy Particles stop and fix themselves at every circuit about the union as well by the motion and action of the subtil, and ethereous mat­ter, [Page 14]as by encountring the external Air, and frame a Callous like that which is made in broken bones? Likewise put in fix Graffs of different kinds in the same Stock,An Experi­ment. you will have the pleasure to see them bear Fruits of as different kinds, which cannot be explain'd without saying that the Juyces, which pass through the Roots, and Trunk of the Stock, have not yet any determinate Figure, but that they receive one passing through the Pores of each Graff; this is an experiment which I relate by the by, because it fortifies the System which I have establisht concerning the Reunion.

Cause of the inequality of the Cal­lous.As for the inequality which re­mains at the Unition, after the For­mation of the Callous, 'tis not diffi­cult to conceive that it proceeds from the too great abundance of salts which rise up to the Surface, where they are stopt and fixt by the action of the external Air, as we have re­marked heretofore.

Having explain'd the principal difficulties that regard the reunion, I conceive 'tis made after this manner. After the Surgeon has cleans'd the [Page 15]Wound from all the grumous Blood,How the Reunion of VVounds is made. and other strange Bodies; after he has exactly brought together the Lips, and endeavour'd to take all necessa­ry care for maintaining them in the same Situation; I say, that the Moli­cule of the Blood (how indifferent, or indeterminate soever they be) pas­sing and repassing from one of the Lips of the Wound to the other by Pipes, which I look upon as so many little Threads, they Frame and Figure themselves differently according to the Configuration of their Pores; it happens that by the different turns and returns of the most Glewing Par­ticles, the most Nourishing and Bal­samick (which heat has thicken'd and hardned) disengaging themselves from the other, rank and apply them­selves to the Mouths of the little Fi­brils, frame as it were a Million of little chains, Horizontally drawn from one Lip of the Wound to the other, for to tye and joyn them ex­actly together. After this manner I shall always explain the Reunion, Vegetation of the Particles, and Pro­gress of Wounds, the losses of which are sometimes considerable. I pass [Page 16]now to the Examination of the Su­tures, and the Circumstances which depend on them.

CHAP. III. Of the Sutures.

Three kinds of Sutures used by the Ancients.THE Ancients have Established two sorts of Sutures, the one of separate Points, which they call'd In­carnative; and the other of continuous Points, call'd Restrictive; they have also spoken of a kind of Conservative Suture, which they used in great Wounds to avoid deformity.

Five kinds of Incarna­tive Su­tures.There be five kinds of Incarnative Sutures.

• 1. The interfected or inter­rupted.
• 2. The Quill'd or Spiral.
• 3. The twisted.
• 4. Hookt. And,
• 5. The dry Suture.

Five kinds of Restri­ctive Su­tures.The Tanners, Shoomakers, Taylor's Stitch, and from without inwards, and that of Celsus which is made a cross, are the five kinds of Sutures, which Antiquity has described to us under the name of Restrictive; but without insisting on the description of these last, because absolutely use­less, [Page 17]I pass to those which are in use,Three sorts of Sutures most in use. viz. The Interrupted, Quill'd, and Twisted, the last being used in the Hare Lip, the quill'd in deep Wounds, and the Interrupted in all others.

'Tis not enough to entertain you with the Sutures, I am also obliged to make you remark all the circumstan­ces which accompany them, after I have given you the most perfect Idea that I possibly can of Wounds, to which they are convenient, and to which not.

Where Su­tures are to be used.The Wounds where ordinarily Su­tures are Practised, are Angular, Transverse, Oblique, in a word, e­very where the Bandage can't make the Reunion.

VVhere not first in al­tered wounds.The Wounds in which Sutures are rejected, are those alter'd by the Air. I will propose my conjectures about its Malign Action in such Wounds.

The malign Quality of Air in wounds.I say, that the Air is a fluid and transparent Matter, full of Saline Nitre, whose Particles are Branch'd and Irregular; this being supposed 'tis easie to draw some consequences concerning the manner how it Com­municates its evil Qualities to wounds, and how its capable to alter the Na­ture [Page 18]of the Blood; which is not hard to conceive, if we consider that it Rusts, not only Iron and Copper, &c. but also corrupts even the most solid Bodies.

I consider the Humidity of the Air, and the Nitre with which it's loaded, as two great Agents, which have the power to consume and destroy the most Oyly Portion of the Nutritive Juyce of the Parts,How the Air destroys the Tone of wounded Parts. so that the Oyl of the Blood, which is the true Balm that Nature makes use of to Re-unite Wounds, and keep the Vessels supple, being dissipated by the Humidity of the Air, and action of the nitrous Salts which are disperst in it, the Fibres dry up, and the Pores contract, which oc­casions very frequent and dangerous Obstructions; the Salts thus having got the upper Hand, and united themselves with those Salts, which re­sult from the consummation of the Oleaginous Particles, that serve them as a Vehicle, change into a Vitriolic and Arsenical Matter, that gnaws, cuts, and corrodes the Vessels; of this mixture arises a kind of Verdi­grease (almost like that we see on Copper) after the Action of this pow­erful [Page 19]Enemy of Bodies; so that if one does not defend the Wounds from its Ravage, it happens that the Obstru­ction and Inflammation encrease more and more, which occasions Fevers, and gives way for a Gan­green to seize the Part.

2. Sutures not convenient in contused wounds.The Sutures are not convenient in Contus'd Wounds, because there is extravasated Blood between the Fi­bres and Vesicles; which must needs turn to Pus; we want no other in­dication to shew us that we must give it vent by way of Suppuration, and so consequently the Suture would be very dangerous.

3. VVhere there's loss of Sub­stance.I say also, that Sutures are not used in Wounds, where there is great loss of Substance, as in Gun shot, or in those whose Lips the Surgeon cannot bring together.

4. Nor in Bites of Venomous Animals.Nor are Sutures made in Bites of of Venomous Animals: For without doubt their Poyson presently Irritates the Spirits which ascend to the Brain, and infects the whole Mass of Blood, which must presently be Remedied by the help of Cardiacs, and Corrobo­ratives, after having apply'd to the Wound strong Resolutives, as Theriaca [Page 20]dissolved in Spirit Vini, and other Medicines of the same Nature.

5. Nor in great In­flammati­ons.They are also rejected in great In­flammations, the understanding of which suffers no difficulty, since the Obstruction precedes always the In­flammation; 'tis necessary that the Matter which is stopt, and out of its Vessels, be Evacuated.

6. Nor where large Ves­sels are wounded.They are of no use, where conside­rable Vessels are open'd, because the Blood which flows from them, the Bandage which one is obliged to make, and the Astringents, which are strange Bodies, oppose the reunion.

7. Nor in wounds of the Thorax.They must also be avoided in Wounds of the Thorax, as well su­perficial as deep, because of the fre­quent Motions contrary to unition, for the Breast being forc'd to dilate and contract, the Muscles and Cutis making an effort in assisting the Ele­vation and Dilatation of it, would burst and be torn, because of the resistance which the Sutures make, which would excite Inflammation, Pain,8. In discove­red Bones according to the Anci­ents. and difficulty of respiration.

Finally, the Ancients have added, that we must not use them in Places where the Bones are discovered, be­cause [Page 21]of Exfoliation, but as there is nothing that alters more the texture of the Bones, and Facilitates more quickly Exfoliation then the Appulle of the Air, we must not question to shelter them by the help of the Su­tures, having a due regard to the Contusions and Fractures which often happen to the Bones. However, be it as it will, we hazard nothing, be­cause, if the Accidents should be ur­gent, we have nothing to do but to cut the Threads; so that one may without danger use Sutures in Wounds of the Head which penetrate even to the Bone; unless they be in the fur­thermost part of the Coronal Bone, or behind the Head, or in a direct Line, then we may use an uniting Bandage: This being known and explain'd, we must speak now of the circumstances which accompany the Sutures that we Practise: They consist in chusing Nee­dles proportionable to the Nature of the Wounds,Choice of Needles. E. Gr. if they be great and deep, you must use a crooked, flat, and very sharp Needle, the Thread must be single or double ac­cording to the force 'tis to resist. In all sorts of Wounds, the Fingers are [Page 22]more convenient than the Canula. Ha­ving taken all these precautions, and freed the Wounds from all Extrane­ous Bodies, a Servant must bring the Lips together,The manner of perform­ [...]ng the Su­ [...]ures. and the Surgeon with a Needle arm'd with wax'd Thread, pierce them in a strait Line from with­out, inwards, and from within, out­wards, making as many Stitches as convenient. You must pierce deep enough into the Flesh, because for want of penetrating, you may leave some space in the Bottom of the Wound, where some Blood may be spilt, which wou'd hinder unition.

An Objecti­on Answer­ed.I am not of their Opinion, who recommend in the Practice of Su­tures to take more of the upper then the under Lip, because (say they) the strength of a Muscle is much more considerable towards its Origin than insertion; but they don't consider in the sensible Action of a Muscle, that when the tendon of the Origin obeys, and is relaxt, that of the Insertion is much brac'd and bended, so much more subject to be broken, if it suffers any Convulsions in some part, from whence I con­clude, that if you were to take more [Page 23]of one Lip of the Wound (which we suppose to be in the Belly of the Muscle) than the other, it wou'd be much better to do so on that which regards the Insertion. But without insisting on a thing of so little con­sequence, I suppose it no way necessa­ry to engage one side more than another.

Finally, all the Threads being past, you must begin to tye that in the middle, making presently a single knot, on the firmest side, and where the matter is least apt to run; over that, apply a little compress of Linnen, on which make another knot, which I believe more useful than the Surge­on's knot (which only consists in twice passing the Thread through the same knot) because if any Accident should happen, it could be more ea­sily united, then make a slip knot, and so of the rest.

If the Wounds are superficial, a strait Needle will serve; single Thread, and your Fingers, obser­ving always the forementioned cir­cumstances. Thread is to be preferr'd before Silk,Thread bet­ter than Silk. because this cuts the Flesh.

If the Wound has but one Angle, you must begin at it, if two, begin in the more solid part; if three or four, begin always by the Angles with little Compresses, or Bolsters. The Balms, and Bandages are at the Sur­geons discretion. If you apply an Emplaster, you must lay little Com­presses on the knots, lest you move them in taking off the dressing.

If there happen any troublesome Accidents, loose the knots without any violence, so that you may tye them again when the Accidents cease;How to cut and draw out the Thread. but if there should happen any conside­rable Inflammation, so that we should be forc'd to cut them, you must intro­duce your Probe under them on which you must cut the Thread: (We do so, when We find the Reunion is made, and that we are about to undo the Stitch with Dexterity) then lay your Finger next the knot, and draw the Thread softly out, for fear you renew the Wound.

These are the principle circum­stances which must be observed in per­forming the interrupted Stitch:In what part the Quill'd Stitch is most used. I pass to the Spiral or Quill'd, which differs from the other, only in the [Page 25]manner of disposing the Threads. We use it for the most part in deep Wounds, which happen to the great Muscles of the Buttocks, and Thighs, tho' perhaps if well examin'd inferior to the interrupted: but seeing it may be useful, and has in all times been esteemed so; I shall now describe how it is performed.

How to make the Quill'd Stitch.The Surgeon must take a crooked Needle, Arm'd with a wax'd Thread, the two ends of which must pass to­gether through the Eye of the Needle, that there remain a sort of Loop, ha­ving pass'd it through the Flesh, you must so dispose two or three of them, according to the length of the Wound, in which you must put some pegs of Wood, arm'd with Lint, some strong Tents of Lint, or a Quill, which must be Rankt all along the extremity of the Lips, which have been brought together by a Servant, who holds them while the Surgeon makes the knots upon the Tents; &c. as has been said, except that we put no Compress on them.

There's one kind of Quill'd Suture, where you can cut the Threads and make the knots on both sides.

The Twisted Stitch is only made in a Hair-Lip, it consists in disposing the Thread, cross about the Needle, as shall be describ'd in the Operation.

The dry Stitch, not very useful.Some put the dry Stitch among those that are in use: But, besides that, this Suture is only fit for Cutane­ous Wounds, and is often subject to come off, I find it useless, not only because of the Humidity which loosens it, but also because 'tis not capable of making an exact Union.

How the [...]ry Stitch [...] made.But they that would make use of it, have nothing to do, but to take two pieces of new Linnen with their Sel­vage, cut in several Angles, or In­dented more or less, according to the length of the Wound; at the Extremities of which, tye some little Fillets, then dip the Clothes in some Agglutinative Medicine, applying them in such a manner, that the An­gles may be a little distant from the edges of the Wound, about half a Fingers breadth, to facilitate the Unition more commodiously.

CHAP. IV. Of the Suture of the Tendons.

TO make an end of the Sutures, I come to shew how that of the Tendons is performed: But be­fore I begin, 'tis necessary to explain the Symptoms which ordinarily ac­company its Wounds. In these kind of Accidents, the Tendon is wholly cut, or in part only, if the former, 'tis evident that the Symptoms are not so bad, and that it suffers neither Tension, Tumor, nor Fluxion, but withdraws somewhat into the Flesh, and increases a little in thick­ness: But if the latter, the Symp­toms are very dangerous, because the Fibres that remain destitute of their wonted assistants, must of ne­cessity be broken and torn in the sensible Contraction of the Muscles, or at least suffer such violent tensi­ons, that cruel Accidents speedily arise; besides that, the Blood spilt,Accidents attending wounded Tendons. in the Intervals of the Fibres, does Fer­ment the Saline Particles, and work­ing upon the Tendinous Fibres divide [Page 28]them, on which follows sharp Pain, Convulsion, Syncope, Vomiting, Diar­rhaea, Fever, Coma, and often Gangreen, if the rest of the Tendon be not speedi­ly cut.

Case of Pain.The Pain is not excited, but by the continual Divulsion of the little insen­sible Fibrils, like that which one feels sometime after the cut of a Sword, this does not proceed from the first division, but by those which are made through the action of the sharp and extravasated Humours,No Pain without So­lution of continuity. so that as of­ten as the Animal feels pain; there are some divisions made, by which means the Soul (which watches and interests it self in the conservation of the parts of our Bodies) is afflicted.

The cause of Convulsi­ons.These sharp Humours, coming to shake vigorously the little Filaments of the Nerves, cause the Spirits to run irregularly into the Muscles, which excites the Convulsion.

The Spirits being put to flight, in­stead of running into the Fibres of the Heart,And of Syn­copes. and ruling their motion, are carried in disorder, sometimes to one part, sometimes to another; the Heart being deprived of the influx of the Spirits, which are the true In­struments [Page 29]of its ordinary motion, and being no more capable of contracti­on, the course of the Blood must be suspended for some moments, from whence comes Syncopes.

And of Vo­miting.But as soon as they retake their course, they double their Action, and are Lanch'd with so great Pre­cipitation into the Fleshy Fibres of the Stomach, through the familiar com­merce and mutual consent between the Cardiac Nerves and those of the Stomach, that they oblige it to dis­charge it self of all that's in it, which is call'd Vomiting.

And Diar­rhaea.The Ventricle with its powerful and repeated Contraction, passes so hard the Bladder of Gall, and the Neigh­bouring Bilous and Pancreatic Ducts, that it squeezes out their Juyces into the Cavity of the Guts, which presently causes a Diarrhaea.

The cause of a Fever.These two Liquors being thus prest out of their Vessels, without having re­ceived all the preparations and altera­tions which are necessary for them; fail not to make the Chyle Acid, with mixing themselves in the Intestines, they serve for Leven, and Ferment to corrupt and produce a Fever.

Of heavi­ness of the Head, and failure of the Senses.The Blood being in Fermentation, mounts with such an impetuosity to the Brain, that the Sinews thereof which receive all the rest of the Blood of the Interior Head, cannot dis­charge proportionably so much Blood into the Jugulars as the Arteries furnish, by reason of the slowness of Circulation in these Sinews; so that the Nerves which come from the base of the Skull, to be distributed to the Organs of the Senses, are a little comprest by the weight of the Blood, which causes heaviness of the Head, and that the Senses don't receive the impressions of their Objects with the same facility as before, through the Obstacle that the Spirits find in their passage.

How to pre­vent those ill Acci­dents.To prevent all these Accidents, you have nothing to do but to cut the rest of the Tendon, if the major part be divided, but if the loss of the Fibres be not so considerable, and the Symptoms not so pressing, you must do nothing rashly. If you perform the Operation, you must Stitch the Tendon, rather than cut it, so that the Surgeons intention is to Reunite the two Extremities by Suture.

If it happen that the Extremity of one part be so far shrunk into the Flesh, that it cannot be brought to the other by the Forceps, it would be convenient to molifie the Fibres a lit­tle with some Oyls extracted with­out Fire, as Ol. Amygd. Dul. Ovor. Cerae, &c. which are proper to re­lax the Fibres, and facilitate their U­nion; for if the Oyl be Extracted without Fire, the heat does not so soon dissipate their Viscosity, which is the true Cement; besides, they are more capable of tempering the Acid of the Blood, and of appeasing pain.

The Tendons being molified, you must Stitch if you can, and seeing they are Compos'd of little Fibres, How to per­form the Operation. you must take half the breadth of a Finger upon the Body of the Ten­don, that the Stich may better resist the motions of the part, and the flow­ing of the Matter. If the Tendon be not discover'd enough, you must try to make the Suture, without unflesh­ing it, because the Flesh secures it from all alterations.

After the Surgeon has put the part in a convenient Situation, a Servant must uphold one Extremity with the [Page 32]Forceps, whilst the Surgeon with his left Hand holds the other, and with a strait Needle, arm'd with double wax'd Thread knotted at the end, pierces them from without, inwards, and from within, outwards, bringing them exactly together; then lay away your Needle, and take a little com­press of Cloth with two holes in it, to pass the two ends of the Thread through, and make a single knot, over, which apply another little Compress, which you fasten with the Surgeons knot, and slip knot; you must ob­serve to wet the Compresses in some Spiritous Liquor, and put some wax Candle on the knot instead of Lint.

The Suture being made, you must humect the first Day with some Oyle and Spirit of Wine, the following days we use a Balsam made of Tereh. Tinct. Aloes, Ʋnctuous Medicices not proper. or that of the Tinct. Flor. Hyperici, the use of Oyls, or Fats, are here to be rejected, because they Pu­trifie the Tendons: In the beginning Cataplasms made of the four Meals, Wine, the Yolk of an Egg, and Hony, are very proper: It must be observed, that as soon as Suppuration is made, 'tis evident, that the Tendon begins to [Page 33]be united; most good Practitioners Commend in long Suppurations to make use of Spirits, on bared Tendons, & Emplas. Andreae è cruce.

CHAP. V. Of the Hair-Lip.

VVhy so called.IF Sutures have any use in perform­ing Operations, 'tis doubtless in the Unition of the Hair Lip, so call'd, because this Animal has naturally the Upper-Lip slit. This Malady comes sometimes from an imperfect Con­formation, and sometimes by Acci­dent, viz. it may be caused by some Blow, Fall, or other like mischance, if the Reunion be then neglected, it's to be fear'd, least the edges grow Cal­lous, and at length a true Hair Lip is form'd.

'Tis very often an Hereditary De­formity, which we keep as long as we live, unless we are willing to suf­fer the Operation; however, its cure cannot be accomplish'd but by Suture: If there be great loss of substance you must not hazard the Operation, be­cause [Page 34]the Cutis wou'd be so much ex­tended, that it wou'd be very hard to Pronounce well certain Words, and to make with care all the other mo­tions which this part is capable of, those which happens to the Under-Lip are of difficult cure, because the Defluxions are more-frequent, and the Lip always humected with many serosities.

Where cut­ting Hair-Lips wou'd be useless.There are several other occasions where the Operation wou'd be use­less, as in Children, by reason of their continual Crying, in the old Scorbu­tick and Pox'd, in irregular Women, and in several other vitiated and in­disposed Subjects, in which the Blood is only a serous Mass, sharp and Cor­rosive, having lost all its consistence and unctuosity, and consequently in­capable of Reunion: You must have regard to some of these circumstances in all other Sutures; therefore the U­nion of the Hair-Lip is not to be un­dertaken, but in adult Persons, who have no other incommodity, and are willing to endure pain.

How 'tis to be perform­ed.To perform this Methodically, you must cut a little Filament which fastens the Upper-Lip to the Gums, [Page 35]to give liberty to embrace with your Instrument the whole breadth of the Hair-Lip. 'Tis a particular pair of Pincers with which you must engage the Lip, towards the corner of the Mouth, and let it slip to the Extre­mity of the slit, you must secure and fasten it with a Ring, to have the li­berty of refreshing and cutting Dex­terously the Superfices; afterwards, you must unbridle the Upper part for fear there may remain a little swelling, which would be as disagreeable as the Deformity it self; so that after the two Lips of the Wound have been exactly brought together, and that they are in a just level, you must pass from one Lip to another, one or two Needles arm'd with wax'd Thread, according to the length of the Hair Lip, and cross the Thread about the Needles as is convenient; you must break off the points, and lay some little Compresses underneath, that they mayn't prick the Patient, then apply a little Pledgit wet in some Balm, or Styptick Liquor, and Em­brocate with Ol. Rosar. with a Com­press dipt in Oxyerate. and a little Band, or the fourfold Bandage.

You must not imitate certain Ope­rators, who Scarifie to no purpose, the sides of the Wound, to disengage the part which always suffers some Tension, since we can remedy this inconvenience, by laying on the Cheeks some Compresses sustain'd by the Bandage; you must order the Sick a very exact Diet, which con­sists in using the first three or four Days nothing but Liquids, and avoid­ing all sorts of motion.

CHAP. VI. Of the Gastroraphia.

OF all parts of the Body, there's none more subject to Maladies than the Belly, and that consequent­ly has more need of the Surgeons as­sistance.

The Operations which are Practi­sed there, depend from the Wounds that happen to it, from the Tumou [...]s called Hernias, from Laborious Child­birth, from Dropsies, Fistula's, and Apostems.

The Wounds of the Belly, are ei­ther big or little, Superficial or Pe­netrating, are made with or without the hurt of the contein'd Parts, which very often come out of the Cavity, according to their indisposition; greatness of the Wound, more or less motion as we are going to explain.

We conjecture there is some part damag'd according to the Figure of the Instrument wounding; you may judge what Parts are hurt by the Situation of the Wound, and by that in which the Patient was when received.

Signs of the wounded Viscera.But the true Signs which indicate the division of some Internal Parts, are acute Pains, Inflammation, Fever, or some Matter coming forth; ne­vertheless, all these Signs are equivo­cal, except the least, which is known by the Colour, Smell, and consistence of the Matter, which is discharg'd out of the Wound, or flows in the Cavity of the Belly.

After what manner the Viscera get out of the Belly.But as the most of these parts are floating and always Relax'd, they get out of their Cavity at the least impression, or disorder, particularly at the time of expiration, when the Tho­rax contracts: Though it seems that [Page 38]they should rather escape in the inspi­ration when the Diaphragm is level'd, pushing back, as the Antagonist of the Muscles of the lower Belly, all the parts that are under it, yet its certain that the Muscles of the lower Belly oblige them against their natu­ral motion and inclination, to come out of the Wound in time of expira­tion, when they press all the contein­ing parts of the Belly: This being so, 'tis evident that it's necessary for the part, that is under the Muscle and out of Action, to regurgitate and shew it self out of the Wound, as a piece of Paste does between the Fin­gers, when squeez'd with the Hand, whereof depend those frequent Stran­gulations, and dangerous Inflamma­tions.

You must also remark, that these parts are extream spungy and greezy, whose Texture is very loose, hu­mected with a quantity of Humours, bedewed with an infinite number of Vessels, and consequently very sub­ject to Putrefaction, for the Air com­ing to strike and penetrate their Sub­stances, they fail not to Tumefie and Condense the Blood which animates [Page 39]them, if they be too long expos'd to it: These Parts being therefore depriv'd of the motion of the Blood, in which con­sists their Heat and Life, there must needs happen a mortification.

Besides the action of the Air, we know that Inflammation is capable of causing the strangulation and mortifica­tion: It's easie to conceive that the parts being inflam'd and swell'd must take up more room than before, and press the Intestine and Omentum, which is com­monly found in the passage,Cause of the Inflation of the Intesti­a. from which must follow interruption of the course of the Blood and Spirits in those parts, and consequently Gangreens. It often happens that the Intestine is inflated, the cause of which proceeds from the Inflammation, which the Wound com­municates to the Gut, and the Air Ob­structs the Pores; besides, the return of the Venal Blood, is in a manner stopt by the Strangulation, and the little mo­tion which is to be seen there.

The Inflammation which attacks the Gut, is capable of Rarifying a part of the Serosity, (and the other Juyces which are contain'd there, whose mo­tion is made more slow) not being able to escape, by reason of the Air [Page 40]which stops all the passages, and shuts the Pores of the Intestine, so that 'tis impossible for the Surgeon to re­duce them without dilating the Wound.

How to Di­late when too narrow.To perform which, the Surgeon must pass a hollow Probe between the lip of the Wound and Intestine, and slip a Bi­story all along the hollow of the Probe; but before he makes the Incision, it will be convenient to examine whether the Gut be not engaged, lest he wound it: This being known, he may boldly di­late the Wound, and cut as much off the Peritonaeum as of the Muscles, &c. because the Strangulation is every where equal, against their Opinion who pretend 'tis more considerable without, than within. I shan't here speak of the precautions which the Ancients took, in applying Fomenta­tions, and several other Medicines: But suppose it necessary to Foment, and warm the parts with hot Clothes, or with Wine.

If the O­mentum be altered, cut off the mor­tified part.Before you reduce them, you must examine whether they ben't hurt, and if the Omentum be not mortified, which is known by its Lividity, then without delay, cut off the Gangreen'd [Page 41]part, after having made the Ligature of that which is sound.

If there be a little Wound in the In­testine, it requires no Suture; if it's big, use the interrupted, for the Skin­ner's Stitch is not approv'd of.

In my Opinion, there's nothing that sooner cures the wounds of the Guts, and procures quicker unition, than a true and exact Diet; and I find nothing con­tributes more to it, than in ordering the Patient to lie on his Belly, taking care to have a kind of Bolster under the Wound, to facilitate the running out of the Matter: Every one knows,In wound of the Belly, a spare Diet to be used. there's nothing more contrary to union, than motion: By the Diet we lessen the Acti­on of the Intestines, and by the Situati­on, that of the Muscles of the Abdo­men: the reason is, that in this Situa­tion, all the parts within, lie heavy on the Peritonaeum and Muscles, and so diminish part of their motion. You must Observe, that Wounds of the Guts are never Reunited, except to the ☜ Neighbouring Guts, and other nigh parts, as Peritonaeum, &c. for which reason, 'tis convenient to past a Needle arm'd with wax'd Thread under the Body of the Gut through the Mesen­terium, [Page 42]chusing a place most free from Vessels, to pull it gently towards the Peritonaeum, to which it will easily ad­here.

Having observ'd these circumstances, search for that part of the Gut which is nearest the Mouth of the Wound,How to re­duce the Gut. and reduce it with your Fore-finger into the Cavity of the Belly, and be­fore you pull that back, introduce the other; and after this manner push it successively till in its natural place. The Ancients used to shake to the Pa­tient, that the parts might return to their former Situation. We always leave out of the Wound a part of the Ligature of the Omentum, which we place on that side where the Matter runs least, and we make the interrupted Suture; hence come the name of Gastroraphia.

How to make the Suture of the Belly.You must have two crooked Needles arm'd with the same Thread, then with your left Hand hold the Peritonaeum, and the other integuments, and taking a Needle with your right, pass it from within, outwards, on one lip, and with­out lifting your Finger, pass the other on the opposite side as the first. You must make as many Stitches as are ne­cessary, leaving some space to put a [Page 43]Tent in, on that side where the Matter takes its course, if there be any appear­ance of Suppuration, which common­ly happens, if the Omentum or In­testine be any way alter'd: Having examin'd all these circumstances, you begin with the middle Stitch, and so of the rest.

The Sutures being made, you must apply a Pledgit dip'd in some Balm, or spirituous Liquor, making a light em­brocation with Ol. Ros. and Spirit Vin. on the region of the Belly, then a con­venient defensative sustain'd with the Napkin and Scapuler. The next day instead of using Astringents, 'tis good to use Emollient, and resolving Fomen­tations to hinder Tension,Tension a dreadful Symptom. which is a dreadful Symptom; for the edges of the Wound endeavouring to retire, cause extream pain, and often break the Thread; therefore you must dis­pose it so, as to be able to straiten it after the Inflammation's over.

Emollient Clysters are of great use, not only because they relax the Fibres, and evacuate the Matter, but also be­cause they refresh, and serve as a Balneum Marie, to calm the motion of the Blood and Spirits, and hinder the [Page 44]progress of Accidents. 'Tis sufficient­ly known, that Bleeding and general Remedies are not to be neglected.

If the edges become Callous, dige­stives are wonderful, because they re­lax the Fibres, take away Obstructi­ons, and facilitate the generation of the fleshy Vesicles, and consequently the cure of the Wound.

Concerning this Operation, 'twill not be amiss to tell you further, that a wounded Person that has a Portion of the Intestine carried away, wou'd Die infallibly, if the Surgeon by his indu­stry does not so dispose the Gut, to let the contain'd Matter run out; that is, he must shew the Gut to the Peritonaeum, and Teguments which make a kind of Anus, that gives the Excrements liber­ty to come forth through the Wound, unless Nature should work by its self, as it happen'd to a Soldier in the In­valids at Paris, which serves us for an Example.

CHAP. VII. Of the Dropsie, which occasions the Paracentesis.

THE Dropsie, as all the World knows, is a Disease,Definition. whose parts where it is made, are (as it were) over­flow'd with a great quantity of Sero­sities.

Division in­to general and parti­cular.We make ordinarily two sorts of them, the general, and particular: The particular (which we will examine af­ter we have Explain'd the Universal) receive different names according to the parts which they attack, as the Hy­drocephalus of the Head, Hydrocele of the Strotum, &c.

General twofold.The Universal are commonly divi­ded into Ascites, Timpanites, and Anasarca vel Leucophlegmatia we will not speak here of the Tympanites, since scarce ever such was seen, and it differs from Ascites, but secundum majus & minus, being always accompanied with many Serosities. I shall stick only to the Arscites and Anasarca, tho' if well ex­amin'd, this last might be reduc'd to a kind of Universal Ascites, In strictn [...] but one so [...] of Dropsie. or might very [Page 46]rationally be comprehended under the general notion of it.

Ascites true or false.Ascites is true or false, the true is caused by a great quantity of Water, that fills the whole Cavity of the Bel­ly, which swells and tumefies it to the last degree of Tension:True. These Wa­ters fall often into the Scrotum, and make an Hydrocele, and when they grow sharp, and pungent, cause several troublesom Accidents, as we shall shew in the following discourse.

False. Difference between false Ascites and Ana­sarca.The false differs from the Anasarca in this, that the last affect ordinarily the whole habit of the Body, and the other is only confin'd to the Cavity of the Belly. The Anasarca consists in the swelling of the whole Body, and the other only in one part: You must observe, that in Anasarca and false As­cites, the teguments only are alter'd, whereas the true Ascites possesses the whole capacity of the Belly: When I say the teguments are only alter'd, 'tis that you may observe, that the Body of the Muscles is not penetrated: Tho' 'tis true, the water swims on the Sur­face, and it's observed in the opening, those who Die of a Dropsie, that their Fibres are whitish, as well as the [Page 47]Neighbouring parts, because they have been too long humected with the wa­ter, but the rest are as firm and solid as those which have not been touched at all. It must also be observed, that in Anasarca, and false Ascites, the wa­ter is sweet, unsavory, and without Acrimony, for which reason, it is not so penetrating, and the Patient is with­out Thirst and Fever, his Urin is sweet, crude and thin; but contrariwise in true Ascites, the Urin is red, muddy and lixivious, the Patient having ex­cessive Thirst, slow Fever and difficul­ty of Urin.

I shall not trouble my self to tell you the Ancients Opinion concerning the cause of the Dropsie,Four chief causes of the Dropsie. but suppose these four things contribute to its For­mation; viz.

• 1. Indigestion of the Chyle.
• 2. Loose texture of the Parts.
• 3. Slowness of the Bloods Circulation.
• 4. A general dissolution of its whole Mass.

1. Indigestion of the Chyle.I begin, first with Indigestion of the Chyle, which almost always proceeds from the alteration of the dissolvents that serve for the preparation, and the consummation of their Oyl and Viscosity; when the Chyle is well tem­per'd, [Page 48]prepar'd and freed from the course Particles, it's nothing but a But­tery Mass which passes into the venae Lacteae, and from thence into the right Ventricle of the Heart, to be united with the Blood which comes from all parts deprived of its Oyl and most active Principles, and serves for a Ve­hicle and Balm for new nourishment. It is this Lactaceous Liquor well depu­rated and extreamly fluid, which en­tertains the parts, and which by its mixture unites and ties in the Heart the two substances of Blood, viz. the white part to the red; which sub­stances well joyned make a whole, neither too fluid, nor solid, but such as Nature judges most proper to cir­culate without Obstacle in the Ves­sels. But if by chance, the Oyl of the Blood, and other Humours (with which it's furnish'd) should happen to be dissipated, either by violent Ex­ercise, too serious Meditations, extream Grief, or by the abundance and exal­tation of the Salts; the Chyle must of necessity grow sour, become Indi­gested, serous, and incapable of any Union; then it's so far from preser­ving the consistence of the Blood, that [Page 49]it rather Dissolves, Liquefies, and dis­poses it to make Obstructions, Rheu­matisms, Dropsie, &c. Because the Ar­terial Blood, not being able to receive, through this Indigestion, and the pre­parations and triturations necessary for the Life of the parts, it's course must be in a manner intercepted, pas­sing into the Vesicles, or rather spaces between the Porosities of the Arteries and Veins, where the little Oyl frees and disengages its self from the other Principles, which it had taken hold of before, to change into our proper Sub­stance; so that the serosity of the Blood being at full liberty, and having lost a part of its motion, pours it self into the spaces which it meets with,2. Loose tex­ture of the parts. and so causes the Dropsie; according to the texture of the parts, which we have supposed more or less lax.

3. Slow Cir­culation.We must now explain that cause which proceeds from the slow Circula­tion of the Venal Blood. That we may have an Idea of it, we must ex­amine by what Mechanism this Blood is carried back to the Ventricle of the Heart, which is the focus of its [...]ion.

How the Venal Blood is carried to the Arte­ries.I set first, omitting the Organs of respiration and the assistance of the Valves, three principal movers, which oblige the Venal Blood to pass through the Heart.

• 1. The Pulsation of the Arteries.
• 2. The Motion of the Mus­cles.
• 3. The Mixture of the Lympha.

If the Pulsation of the Arteries be weakned,1. Pulsati­on of the Arteries, help the motion of the Blood. the motion of the Venal Blood must be lessen'd, because the Arteries beat, and actually Flagellate those Vessels, and so oblige the Blood which they contain, to repair to the Heart with a wonderful facility.

2. Motion of the Mus­cles.The Motion of the Muscles, is much more important to hasten the Circula­tion of this Liquor, they being as so many Hands which press the Vessels that penetrate or pass through them, and determine the Liquor which they contain to a quicker discharge into their Recepticles: So that if they have lost a part of their motion, for want of Spirits, the Circulation of this course Blood, wou'd be as it were supended in the Veins.

3. The Lympha.In the third place, I said that the Lympha disposes it self in the Veins to make the Blood more fluid and fit to circulate: No 'tis certain, if its [Page 51]course be impeded, either in the Glands or Lymphatic Vessels, the Blood wou'd circulate much slower, for want of a dissolvent. This being suppos'd, that Indigestion of the Blood, slow and dull Pulsation of the Arteries, weak motion of the Muscles, and interrup­tion of the course of the Lympha, are causes which concur somewhat to Impede the Circulation of the Venal Blood,The Venal Blood very poor. which is a Blood depriv'd of its Spirituous Particles, having no con­sistence or strait Union between them: Then the serosity which serves the rest of the Blood as a Matrix, separates it self from it, as the serosities of Milk from the Curd; it transpires between the intervals of the Fibres, or pours it self out as a gentle Rain in some capacity, for to frame both kinds of Dropsies.

Two Experiments confirm me in this Opinion. The first is, That if we make the Ligature of the Veins in some part, and that one hinders the passage of the Blood, it does not fail to be overflown in a short time.

Big Bellied Women sub­ject to Hy­dropical Leggs.The second is, we observe, That most big Bellied Women have Hy­dropick Legs, or at least Varices: This [Page 52]is a Matter of Fact, not to be disputed, and which is easily explain'd, only by the disposition of the parts; we observe, that as the Foetus grows bigger, it enlarges the Matrix, and compresses so much the Iliac and crurel Veins which are near, that the Blood which comes from the inferior parts, not having the liberty to move as it us'd to do, by reason of this compression, there must a Dropsie follow, as we have shewn.

Dissolution of the Blood.What belongs to the cause of the Dropsie, which proceeds from the dis­solution of the Blood, we have already remark'd, when he spoke of Indigesti­on of the Chyle, that nothing is so capable of destroying and consuming the Oyl of the Blood, as the abun­dance and exaltations of the sharp and tartarous Salts. It's by the means of their action, that we explain how Scorbutick, Hypocondriac, Lienteric Persons, and those who lie long in Prisons, become Hydropical: Which we cou'd not easily demonstrate, if we did not admit the motion, and agi­tation of the cutting, and Corrosive Particles, which puts the principles of the Blood to the rout, and disunites [Page 53]them, so that the Sarum escapes on all sides, and gives way for the Dropsie to seize on some part; whether it transpires in form of a Dew through the Tuni­cles and Membranes, or Filters between their Fibres, or the Glands let it escape, or it's spilt by the interruption of its most insensible Vessels, in the void spaces which present themselves at their passage: It will always be truly said, that the parts which Nature has a mind to attack, are in a very little time Drown'd. We observe that the Muscles of all Hypocondriacs are de­prived of a part of the Spirits which are necessary to them for their natural motion; for if we consider, that the Sulphur which we have supposed to be destroyed,VVhat the Animal Spirits are. contributes only to the generation of the Anima [...] Spirits; that the little cutting Particles which this Sulphur wraps up, are the Matter of them, and the residue, the Vehicle and true Oyl, with which the Brain is imbued; we shall agree that the Glands of the Brain furnish very few Spirits in these Diseas'd Persons, whose Bodies are depriv'd of Fat, and that consequently their Muscles must lose of their force, vigour, and motion; [Page 54]from whence comes the great heavi­ness which they feel. You must also observe, that they are no more pro­vided with this Fat, which before made their Fibres supple, flexible, and capable of activity: This being so, 'tis evident that their motion must be weakned, that they can no more communicate any to the Vessels; the course of the Liquors must be slack­ned, and the Animal Spirits which bring some formality to every part, are no more in a condition to keep the Pores open, or at least so wide as ordinarily, so the Vessels being as it were sunk, and the Arterial Blood not having any more the power or strength to make it's way, the parts are almost defrauded of Life.

I alledge all these reasons, because they fortifie our System of the forma­tion of the Dropsie,Old Men very subject to the Drop­sie. which is founded on the slowness of the Circulation of the Blood; which is remarkable in old Men, who are most subject to Dropsies: The reason is, because their Blood is only a fluid Indigested and corrupt Mass, having lost all its con­sistence and unctuosity; one may say, it has lost its Oyl, and consequently [Page 55]is made incapable of sustaining its Fer­mentation. I add, that those who In­habit Boggy places, being of a cold Temperament and used to moist Food, will be more liable to it, than others.

The Dropsie, which often effects Fat and full People, who, neverthe­less, are in a certain moderate repose, has for its cause only the slowness of Circulation, through the frequent Obstructions which ordinarily happen in the Glands, and Vessels, which oc­casions the Lympha to disengage it self, and overflow some part.

VVhen the Dropsie is incurable.The waters sometimes gather toge­ther in a Cystis, which makes the Dropsie incurable: This Cystis is a strange Covert, at first insensible, but by degrees separates it self from some other covering, either of the Perito­naeum, or elsewhere, by the saline and lixivious nutriture which it has con­tracted, or by the too great humidi­ty received, after the same manner as the Particles of an Egg, or Seed dis­engage, or unfold themselves. This Cystis is sprinkled with a multitude of Glands, and Vessels which it receives from the part from whence it derives its Origin, and from other Neighbour­ing [Page 56]Parts which are as so many sour­ces that produce new Dropsies.

Signs of the Dropsie.The signs of this Disease are swel­ling of the Belly, transparency of the Waters, and Fluctuation.

Difference between corpulant persons and hydropical.Before I speak of the Accidents, 'tis necessary to give an Idea of the dif­ference between the swelling of the Dropsie, and a good habit of body. In the Dropsie the Belly is extreamly extended and even, the Navels rises and terminates in a point, whereas in the latter its soft, and less extended, being more elevated on the sides than elsewhere, where the fleshy Portion of the Muscles lie, and the Navel is quite hidden.

Symptoms of the Drop­sie.The Symptoms which accompany this Disease are slow Fever, weak, Pulse, heaviness of the whole Body, difficulty of Respiration, considerable Swelling, excessive Thirst, and difficulty of Urine.

1. Slow Fe­ver.The slow Fever is nothing else but an effect of the impurity of the Chyle, and other levens which intimately mix with it: this mixture design'd to make the life of the part happy, being impressed with this brine, or rather charg'd with this impure and strange Matter passes to the Heart how corrupt soever it be, [Page 67]where it ferments and disorders its motions, the Heart communicating its unruly Pulsations to the Arteries, excites this kind of Fever which is only felt very slightly.

2. Weakness of the Pulse.The Pulse's weakness depends on the slow influence of the Animal Spirits in­to the Fibres of the Heart, which being incapable to augment their Action (in respect of the Spirits as well as Blood, by reason of their scarcity) maintain the blood in that little degree of preci­pitate motion which distinguishes this slow Fever from the other, and con­sequently causes this weakness of the Pulse.

3. Heaviness of the Body.The pale colour, and heaviness of the body, proceeds from the slow motion of the Blood, and from the dissipation and concentration of the Spirits, which are stifled and choak'd (as it were) in the Waters: now as the heat and vigor depend on the presence, and natural ferment of the Blood and Spirit, which should animate these parts, and be car­ried to the Surface, you must not wonder if they be so pale, and if the Muscles can't sustain the weight of the Body.

4. Difficulty of RespirationThe difficulty of Respiration is cau­sed [Page 58]by the swelling and great tension of the belly which presses the Dia­phragm against the Lungs, and dimi­nishes the Diameter of the Breast, so that the Lungs having not the liberty to extend themselves, the Respiration grows frequent and forced.

The excessive thirst is rais'd from the humors that are separated from the Glands of the Stomach,5 Thirst. Oesopha­gus, and other parts of the Gula to moisten their coasts, and to maintain them in the Humidity which is re­quisite for them, it's not enough either through the frequent setlings which are made in other parts, or that the in­vincible and intemperate fire, which the Fever kindles in all parts, dissipates, consumes or ratifies it, which cause these parts to heat and dry, and that saltish Spirits, whose actions are not corrected by any dissolvent, rush into the little Fibres, and produce a motion in the Nerves which excites thirst.

As to difficulty of Urine, I suppose that part of the Water which used to take its course through the Kidneys,6. Difficulty of Ʋrine. tends another way, and that the Uri­nous, Volatil, and other fixt Salts of the Urine, being deprived of a part of their [Page 59]dissolvent stop at the entry of the Pores of the Glands, and hinder the Urine from running with that liberty into its Conduit, the Salts thus having the upper hand, and finding nothing in the Blood capable to blunt their points, irritate all the parts through which they pass, particularly the Areteries, and o­blige the Sphincter of the Bladder to a more than usual contraction, which causes the Urine to flow very difficult­ly, and by turns.

I pass to the cure of this Disease which is perform'd by the help of Me­dicines,Cure. or Operation. The most Specifick Remedies are diureticks, and those which cause insensible transpira­tion, others being of no great use.

The strongest Diureticks are Rad. Tinctura Diuretica. Ebul. Irid. Erysimi. Cucum. agr. fol. Solda nel. Cerefol. infused in Spirit Vin. Mercuri­sati. It's an extraordinary remedy.

Infusus Anthydro­piens. Rad. brusc. Polypond. Gladiol. Medul. sambuc. Croc. & Chryst. miner. infus'd cold in White Wine, make a wonderful remedy. Sal. Rut. Crem. Mercurii Spirit. Salis: taken in Broth (without common Slat) are admirable. There are several other Medicines of which Authors are full; I mention here only those which I have experimented.

If all these won't do, you must proceed to the Operation which con­fists in punction made on some part, its name differing according to the place where it practised, being call'd when made in the belly, Paracentesis; in the Scrotum, Punction; and in the Legs, Scarification.

CHAP. VIII. Of the Paracentesis.

OMitting the Description of the me­thod of the Ancients, I proceed ours,VVhere the Puncture is made. wherein we use the Trocher, or Lancet, the puncture being ordina­rily made on the side four Fingers from the Navel. If with the Trocher, we make no apparatus, but pierce the belly as often as we will draw water from it:Description This Instrument is of a triangu­lar Figure, and scatters only the Fibres, they upon its being withdrawn exact­ly reuniting again; it must always be accompanied with its Canula, when the punction is made, which we leave in the Belly as long as the water is to be drawn. If you use the Lancet, you [Page 71]must arm it with a little band of cloath before hand,Method of using the Lancet. and thrust it in till the water comes forth; and before you withdraw it, introduce a Probe on the flat of it, to facilitate the passage of the Canula into the Belly, then having drawn a sufficient quantity according to the strength of the Patient, stop the Canula with a small Tent, and apply good compress sustain'd with napkin and scapuler: but seeing that by this method we can't always hinder the ra­pid stream of the water we must prefer the Trocher.

In what parts your Operation is useless.You must observe that the Dropsie of the Head, Breast, and Stomach are never cur'd by Operation, but by ge­neral Medicines.

CHAP. IX. Of Hernias.

THE Belly is subject to certain tu­mors call'd in Greek,Definition. Cele, in Latin, Hernia v. Ramex. 'tis defin'd a preter­natural Tumor caus'd by the falling of some part, or gathering together of some superfluous Humor.

VVhat Her­nia signi­fies.The word Hernia, signifies something that's troublesome to bear: I'll use the Etymology in opposition to their opi­nion, who pretend it suits not with the Humeral Hernia, and I believe every one will agree with me, that they are insupportable as well from Humors as Parts: Hence I conclude the word Hernia may fit all kind of Tumors which happen to the Belly or Scrotum. I confess the word Rupture is only applicable to those in the Groin and Scrotum, from the Omentum, Inter­stines, or some other part. But omit­ting a useless multiplication of imagi­nary names, I pass to its species and differences.

And these are drawn from the parts which they attack, and the different causes which they produce;Names. by reason of the Parts they are call'd Exom­phales, viz. of the Navel: Bubonocele, of the Groins: Oscheocele of the Scro­tum: and Ventralis Hernta, of which hereafter.

By reason of the causes which pro­duce them, the one are made by parts,Diferences. the other by the humors: The first are call'd Enterocele, when the In­testines come forth, Epiplocele when [Page 63]the Omentum, and Enteropiplocele when both.

The latter are call'd Hydrocele, Pneumatocele, Sarcocele, Varicocele, and Circocele, from Water, Wind, Flesh, and other Liquors, which are capable to dilate the Vessels.

Those made by the parts are call'd true, the Humoral false; compleat, true, or Lips of the Womb; not com­pleat, when they don't pass the Groin.

Causes, External.Causes are external or internal; the external are violent blows, great shak­ings, long courses or running, dancing, leaping, continual crying, vehement coughing, excess of venery, too frequent and forced breathings, and generally all the exercises, and strong efforts to which we are subject.

The Internal come first from the in­flux and deposition of a great many Serosities,Internal. 1. which sometimes come from the Glands of the Intestines, or the Groin, but principally from those Glands which garnish the interior Sur­face of the Peritonaeam, all these sources make that abundance of Lym­pha which actually Humects, Relaxes, and Lubrifies these Parts: and conse­quently [Page 92] [...] [Page 63] [...] [Page 64]puts them into a condition to yield the more to the frequent and reiterated Impulsions of the Intestines.

The second, I suppose, depends on the great Dissipations of the oily Par­ticles, for if we consider that the Peri­toneum is near the Omentum and Me­sentery, the two chief Repositories of the Fat, by which it is actually sepa­rated from the Parts, by the heat, it's easie to understand that these Parts con­tinually greasing the Fibres of the Peri­tonaeum, so soften and extend them, that at the least action or motion they give way very easily to the blows, and to all motions which may contribute to their formation.The People of Provence mighty Sub­ject to Her­mat. Hence the People of Pro­vence, the Religious especially, who eat nothing but Oyl in their Food are more subject to Hernias than others.

To the third,3 abundance of wind may contribute, whether we swallow it with our Food, or it be contain'd in it, or produced by the setlings and heap of a considerable quantity of dissolvents, which by an excessive heat rarifie, and may be truly supposed capable of ex­tending the Intestines like a Bladder, and of blowing them up to a certain de­gree of Tension, so that taking up more [Page 65]room than usual they impel the Surface of the Peritonaeum, and nesting themselves in these productions form the Tumor.

For the fourth,4 the Dropsie and Fatness in Women may be admitted, this last pushing all the Parts against the Dia­phragm, and determinating them rather to form the Exomphalos than Bubonocele, the other Humects and Relaxes the Peri­tonaeum so considerably, that after the dissipation of the Water it can no more resist and support the Motions of the In­testines.

I pass to the Consequences which we must draw from the Causes of Hernias, relating to the Structure of the Parts where they are form'd, which depend as well on the disposition of the Peritonaeum as the. Mechanick motion of the Dia­phragm, Muscles of the Abdomen, and Intestines.

Hook on the Peritonaeum as a Membrane of a considerable thinckness dispos'd in the shape of a sack, containing all the Parts of the lower Belly; 'tis so long as to reach to the Navel and groins,What's to be consi­der'd in the Peritonae­um. to accompany the Umbilical and Spermatick Vessels which run between its Duplicature; this is in short the Idea you must have of it.

VVhat a­bout the Muscles.Let's now examine the Muscles of the Abdomen, whose carnous Portions gar­nish [Page 66]the Lateral Parts, and their Aponeu­roses occupy the forepart of the three Regions; three of which Muscles are perforated towards the Groin for the pas­sage of the Spermatic Vessels: The first hole is of an Oval Figure belonging to that Aponeurose of the external oblique, and being dilated well enough, represents the handle of a Hamper, whose two extre­mities are fastned to the Os Pubis reaching a little towards the Crest of the Os Ilium.

This hole is lin'd externally with a lit­tle thin and delicate Membrane, which accompanies the Cremaster Muscles to the Testicles, and is nothing else but an expansion of the Tendinous Fibres. The other two are of the Separations of the fleshy Fibres of the Internal Oblique, and Transverse: These three Rings don't di­rectly answer one another, being sepa­rate about three or four Lines. The first that presents it self to us in perform­ing the Operation, is that of the exter­nal Oblique, which is the lowest, and in which is made almost all the Strangulation of the Gut, because the Tendinous Fibres don't obey so well as the Carnous, and are more subject to inflammation; for which reason 'tis that most don't scarifie this ring in the Operation; that of the Internal Oblique is a little higher, and [Page 67]that of the Transvers highest of all; it's easily observable, that if nature had plac'd them one against another, there wou'd at the least effort happen a Hernia. The right Muscle reaches from the Cartilago Ensiformis to the Os Pubis, lying all along the sides of the Linea Alba, and seems to be divided into four Mus­cles which are distinguished by four Ten­dons call'd by the Antients Enervations; this Muscle partly obscures the Motion of all the others, which otherwise would so strongly compress the Guts, that if it, like a movable Bar, did not oppose their powerful contraction, they would oblige the Parts every where to regurgitate out of the Belly.

What the Linea Al­ba is.I'll add a word or two concerning the Linea alba, which is formed by the union of the Tendinous Fibres of the Aponeu­rosis of the oblique and transvers Muscles which Aponeurosis make a kind of sepa­ration, and mark the interval between the right Muscles; so that to shew these two Muscles, we are forc'd to cut those Apo­neuroses under which they are hid: I pass now to the action of every Muscle in par­ticular. The external oblique pass ob­liquely from above downward, according to the disposition of their Fibres, just as the internal pass from below upwards. [Page 68]The transvers press equally the Flanks, and the action of the right is felt all along the sides of the Linea alba: These Muscles so dispos'd, press equally all parts of the Belly, when they are contracted, in time of expiration, and maintain it in a level always united.

After all these reflexions, if we make a just application of the causes of Hernias, according to the Mechanism of the parts where they are felt, we shall find some­thing to satisfie our curiosity, confider­ing that violent blows, rude shakings, long courses, excess of venery, dancing, leap­ing, and generally all efforts are capable, not only of moving the Guts, but also of relaxing their connexions, hence Posts, Postilians, Dancers, Leapers, &c are trou­bled often with them; To these we have added Crying, vehement Coughs, and all too frequent expirations and inspirations, hence, Musicians, Singers, and Children (whose parts are soft and spongy,) are so much subject to them.

In all these efforts, the Guts are so pres­sed, and repelled on all sides by the Dia­phragm and Muscles of the Abdomen, which as so many Hands and movable Napkins, oblige the Omentum and Inte­stines to strike and apply themselves so strongly against the surface of the Perito­naeum, [Page 69]that they are constrained to regur­gitate through the weakest places, as a piece of Wax between the Fingers when it's squeez'd with the Hands, they push, I say, and dilate the interior Membrane of the Peritonaeum, where it's least affisted by the exterior, and sink into the rings of the Muscles forming a Sack, which is greater or less in proportion to the strength of the Impulse. This Sack nests its self all along, and at the sides of the productions of the Peritonaeum,An Ancient Error con­futed. which are form'd by its exterior Membrane, and not in the pro­ductions which invelop the spermatic. Ves­sels. as most imagine: This Idea we must have of the formation of the Purse, which includes the Intestine, and which makes the Hernias, if there be any little indispo­sition in the Oyl, Water, Wind, and Tu­mours, which we have establish'd for in­ternal causes.

The Ventral Hernia remains now to be examin'd,Cause of a Ventral Mernia. which happens sometimes between the right Muscles, sometimes between the Navel and Flanks, exactly at the Aponeurosis of the Muscles, to be convinc'd of which we are only to repre­sent to our selves, how strong the moving force of every Muscle is, which occupies the Flanks, different from the Aponeuroses which have no other motion than that, [Page 70]which their carnous part communicates to them; for though it be true, that all the Muscles Reunite themselves to one sole point of the Navel, where the concourse of their action is, yet it's probable that their carnous part is much stronger, and more vigorous, and by that means more capable of resisting divers shakes of the Intestines, as experience teaches us, unless it be bruised, or cut by some blow: We observe also, that that the Ventral Hernia never happens in the carnous part of the Muscles, but always in the Aponeuroses, or in the space between the right Muscles, particularly, in the course of some fatness. For in these kind of tumours, the Belly rises, so that it obliges these two Musculous bands to part, and the Intestines finding weak places, fail not by their impulsions, to dilate these parts, and so cause the Her­nia Ventralis.

Hernia ventralis and Exom­phalos, not so common as Bubono­tele.If this, and Exomphales, are not so com­mon as Bubonocele, 'tis because the parts, and Humors are more inclining to be car­ried downwards towards the Groins than elsewhere; and the disposition of the rings of the Muscles, which contribute the more to it, as their overtures are wi­dened and relaxed, so that if the parts are put in motion, they insinuate themselves, and slip insensibly through the opened pas­sages, [Page 71]and where least resistance is made.

Fabritius Hildanus relates,Hernia caused by the descent of the Spleen. that he has seen a Hernia made by the descent of the Spleen, this curious remark shou'd move the Surgeons, call'd to this kind of Disease, to pronounce not always in favour of the the Epiploon and Intestines, before good examination, particularly, when the tu­mor is of an extraordinary bulk, since the ligaments of the Liver, Pancreas, and Kidneys, being relax'd,Also the o­ther Viscera they may as well as the Spleen, contribute to its formation. According to the order, I design in speak­ing of so nice an Operation, I think it more proper, successively to describe the Signs of all kinds of Hernias, that I may not confound them.

Signs of Hydrocele.I begin with those of the first kind of Hydrocele, in which the waters are spilt between the Membranes of the Scrotum, which are light tension, considerable large­ness, heaviness, we feel an undulation when we handle the tumor, and perceive the transparency of the waters when we hold a light behind, and the skin becomes ten­der, soft, without pain, and looks extream­ly shining.

In those of the second kind, where the waters possess the Membrane of the Testi­cles, are great tension, pain, greater heavi­ness than in the other, the skin of the Scro­tum [Page 72]is not so much extended, and keeps its rugosities, though it be very much swell'd, through it be very much swell'd, it possesses ordinarily but one side, the Fluctuation's deep, the transparency more obscure. It's to be observed, that these two sorts may conjunctly meet toge­ther.

Signs of Sarcocele.The signs of Sarcocele are, great hard­ness, insupportable weight, and insensible augmentation of the tumor, if there ap­pears no elevation in the Groin, it's a sign that the preductions of the Peritonaeum are not accompany'd with any carcino­matous substance: It's distinguish'd from the Hernia Intestinalis, that the one's soft, the other is hard; this tumor may be di­vided into Scirrhous and Malign, in the Scirrhous we feel neither heat nor pain, but in the Malign, an excessive heat, and sharp burning pain.Varico­ [...].

Signs of Varicocele are great inequali­ty; heaviness, pain, and Inflammation, par­ticularly, when it's irritated with some Medicine; it's also known because it makes a Man somewhat impotent, especially, when it possesses both Testicles.Circoce.

Signs of Circocele, which is caus'd by the dilatation of the external Vessels, diffe­rent from the Varicocele which comes from the Internal, are the same as the for­mer, except there is less pain, weight and [Page 73]Inflammation; add that the Membranes of the Scrotum are more extended, and the tumor more apparent.Of Pneu­matocele.

Signs of Pneumatocele are, when the tumor disappears from time to time, it sounds like a Drum, when it's struck with­out pain, weight, and inflammation, very transparent, the colour of the Cutis changes not, and the Wind is felt, sometimes above sometimes below.Sings of Hernias made from the parts.

Let's now examine the signs of those Hernias, which are caus'd by the parts, and enquire exactly into them, because 'tis of the greatest importance. In the begin­ning of these Hernias, they are ordinarily soft, without inflammation, change of co­lour, disappearing at the least pressure, ex­cept they be caus'd by some Blow, Fall, or such-like inconvenience, and are not ac­companied with some Strangulation, cau­sed by Matter, stopt and harden'd in the Intestines, either by the course of the Blood and Spirits in these parts, which pre­sently excites inflammation, and often mortification; therefore you must do no violence to the tumor by rude handling, lest it occasion a Gangreen; but that we may have a clearer notion of all these signs, let's examine them in particular, and see what are those which make us di­stinguish all these kinds of tumors.

[...] that [...]ut isIf the Gut be engaged, without Inflam­mation, Strangulation, or adhereing to any part, the tumor's soft, plain, and the co­lour of the skin not chang'd; it disappears from time to time, particularly, when the Party lies on his back: When the Intestine is reduc'd, a kind of whistling noise is heard.Signs of the Omentum.But if it's in Omentum, the tu­mour's soft, and doth not return so easily. It's unequal, by reason of the Bands and Fat with which it's charg'd; when press'd with the Fingers, there remains a mark, and we feel the same resistance as in pres­sing a Steatomatous tumor: This is more subject to mortification, because the tex­ture of the parts of which it's formed, is loose, spongy, and more subject to corrup­tion, so that at the least impression, the Blood stops more easily there, than any where else; wherefore, you must not de­lay the Operation in certain occasions, as we shall hereafter mention.

Note, That if Inflammation happen, it's always at the Intestines side; if it's the Omentum, it grows livid at the least alteration

Inflamma­tion, a ve­ [...] severe [...]mptome.As for the Accidents, I find none more dangerous than Inflammation, which is al­ways accompanied with pain, Fever, Stran­gulation, and sometimes with the Illiac passion, where the excrements are often [Page 75]forc'd against their own weight to mount, and come out of the Mouth, the cause of which cruel Symptom proceeds from the Guts, being inflam'd by the excrements which are lodged there: It communicates this Inflammation to the rings of the Mus­cles, particularly to those of the external oblique, which by reason of its tendinous Nature, fails not to shut up the Gut, and augment the Inflammation by a reciprocal action, which causes interruption of the course of the Blood and Spirits in that part; from thence comes the reflux of the excrements, lividity and mortification. It's easie to conceive that, having lost their motion, there can follow nothing but di­vulsion, pain and loss of Life.

There's yet another kind of lividity which comes from having handled and press'd the tumor too much: These un­profitable Touchings are as so many Brui­ses, which are imprinted on the part, the Gut and Omentum being press'd, the Blood stops in the Vessels, which causes immediate mortification, and change of colour.VVhen the Surgeon ought to a­void the O­peration. It's also known by the pain which is greater, as we have said; The Surgeon seeing all these bad Symptoms ought to retire.

The rest of the Accidents I reserve till I describe the manner of performing the Operation.

An Idea of the Ʋmbi­licus.I begin with the Exomphalos, but be­fore I enter on the Operation, I design to give an Idea of the disposition of the Na­vel. It's form'd by the Reunion of the Umbilical Vessels, which slip obliquely in­to the thickness of the Peritonaeum, which accompanies them, and piercing conjuct­ly the Linea alba, fasten themselves to the surface of the Cutis, where they leave a little tumor, which is call'd the Navel af­ter the Birth. In the Foetus, the way through which these Vessels pass, are as manifest as the rings, of the Muscles of the lower Belly, are in Adults, but after the Birth they shrivel up, and turn into Ligaments; and as the parts where these Vessels meet grow bigger. They oblige the Navel by their own weight insensibly: From which I conclude, that all the diffe­rence between the passages of the Umbi­lical and Spermatic Vessels is, that the lat­ter are easily distinguish'd and separated one from another, whereas those of the Navel are not at all distinguishable, because they shrivel up, and the tendinous Fibres of every Aponeurosis twist themselves so one into another, that all their parts seem to be continuous. It must also be obser­ved, that the Navel is without Flesh about half the breadth of a Finger round about, all this contributes to the formation of the Exomphalos.

CHAP. X. Of the Operation of Exomphalos.

AFter having us'd Bandages, and all Medicines, as well general as particular, without success, you must pre­pare the Sick to the Operation:How to per­form the Operation. Being dis­pos'd, the Surgeon must lay him on his Back, without violating the tumor, and en­deavour to reduce the Intestine into the Belly, pinching up the skin on one side, whilst a Servant does the same on the o­ther, and with a Bistory incise all along the side of the tumor,Danger of the Suspen­sorium He­patis. that he may avoid the Umbilical Vessels, particularly the Sus­pensorum of the Liver, for this Visera be­ing no more suspended, the vena cava would be comprest, and the Circulation hindt'd, which would cause Death.

If you are sure of the reduction of the Intestine, you must softly incise still into the Cavity of the Belly, and scarifie the Lips of the Wound in all its extension, to procure a strong Cicatrix; make the in­tersected stirch; some pretend the Quill'd Suture is more covenient, because it more strongly refists the motions of the Muscles and Intestines. You must intro­duce the Tampion of Lint tied to a Thread, to hinder the regurgitation of the parts, and to give way to the Matter; [Page 78]as it Incarns, you must diminish your Tent proportionably, till the Cicartrix be form­ed. Here good Diet, and repeated Cly­sters are to be preferr'd before other Re­medies, as in Gastroraphia.

This Operation includes other particu­lars, which will more properly fall under the Discourse of the Bubonocele.

CHAP. XI. Of the Operation of Bubonocele, and Hernia Compleat.

THat I may not confound all the cir­cumstances which accompany Bu­bonocele and Hernia compleat, nor mi­stake in the order which I have propos'd in describing them. I am forc'd to com­prehend them both in one sole Operation.

These tumours are either wandring or permanent, they disappear sometimes, or remain always in the same condition. If they are wandring, 'tis a sign of no adhe­rance, and that the Intestines suffer no compression, than the Bandage alone, and general Remedies well ordered, may finish the cure. If they be permanent, it comes from the inflammation adherence, or from some excrements hardned in the Intestines: We know when the Epiploon is fastned there, by the signs spoken of heretofore; [Page 79]which induces us to make the Operation without irritating the tumour, for it alters at the least impression, and it is very hard to reduce into the Hypogastrium.

I have made you observe, that the In­flammation and Strangulation succeeded the induration of the excrements contain­ed in the Gut, according as it swells and grows thicker by the flowing of them; the ring of the external oblique, which does not obey as the others, for the reasons al­ready mention'd, restrain sit proportionably as it dilates, which causes the Blood and Spirits not to circulate with the same liber­ty, and the Inflammation of the Intestine to increase equally with the Strangulation. You must also observe, that the Gut never contracts any adherency, but with the bag that makes the Hernia, unless some sharp and strange Matter has cor­roded it.

This bag is sometimes adherent to the cover of the Spermatic Vessels, sometimes to the Omentum, or to the rings of the Muscles in all their circumference, or in some part only, to the Dartos, or finally to the Membranes of the Testicles;The most difficult part of the Operation. so that the Intestine cannot return into the Belly, unless separated by Incision, which neces­sitates the Surgeon to use his utmost Pru­dence and Dexterity, if he means to suc­ceed [Page 80]in so nice an Operation; the chief circumstance of it indeed, being careful­ly to examine where the Gut is fastned, not only because the oeconomy of the O­peration must be changed, but also be­cause this Knowledge rules our Judgments, and causes us to make a favourable or dangerous Prognostic.

A danger. our Symp­tom.The Hernia where the Intestine is ad­herent to the Testicle, is very dangerous, and for the most part mortal. If it be an old one, the happiest can't be rid of it, without loss of the Testicle. The true way to know whether there be any cohe­rence, is to question the Diseas'd, how long 'twas since the tumor did not disappear, whether he feels vehement and pulsific pains, and great weight on the Testicles.

Signs that the Gut ad­heres to the Testicles.If the Intestine be one fallen down in­to the Purse, and that it keep there some time without returning, and there appear no Inflammation in the Groin, it's a sign that the Sack which contains it is joyn'd to the Testicle, by the action of the vis­cous Humors which run from the Peri­tonaeum, or even from the Membranes of the Testicle, these Humors growing thick by heat, are like a kind of a Glew which ties them close together, and if the Matter come to dry up by the reaction of the Blood and Spirits, it's impossible to sever [Page 81]them without offending the Body of the Testicles. You must observe, that if the Gut does not return into the Belly, 'tis not always a sign of adherence: It may be in­flam'd, or contain some excrements, which is the better distinguished, because we know that it had the liberty to enter be­fore the Inflammation. We commonly undertake the Operation when the In­flammation hinders the Matter from en­tring the Intestines.

Having examined the different conditi­ons of the Diseas'd, if there be any of them which induces up to perform the Operati­on, we must use this method.

How to per­form the O­peration.Lay the Patient on his Back (I suppose here, that the intestine is stopt in the Purse, fastned to the Testicle, and Inflam'd) then Incise with the Bistory the skin of the Scrotum, near the Thigh, all along the tumor, then separate the two Lips of the Wound, for to break gently with a Fleam, or your Fingers, all the tegaments of the Intestine and Testicles.

How to di­stinguish the Gut from the Sack.As for the precautions which we must observe to distinguish well the Intestine from the Sack, which forms the Hernia, its brown colour, I suppose, is the most convincing Sign, by reason of the many Blood Vessels which irrigate them: It forms a kind of Arch which is sensibly [Page 82]perceived when discover'd; besides if it's the Gut, the tumor lessens: It's always thicker than the Peritonaeum, being com­posed of four Tunicles. I agree, that this Sign is equivocal, so much the more, because the Sack of the Peritonaeum grows often to a very considerable thickness. There runs always frem the Intestine a thick and stinking Matter; whereas from the Sack of the Peritonaeum, comes only a clear and lump water. The Intestine obeys when you pull it, provided it ad­here not to the Neighbouring parts, diffe­rent from the Peritonaeum, which obeys very little, and the Patient feels always a dull pain: These are the chief Signs which ought to make a Surgeon circumspect. I pass to the particulars of the Operation. The Intestine being discovered, you slip your hollow Probe between the Mem­branes of the Scrotum, and the Body of the Intestine for to widen the Aper­ture, and to discover it naked, to be able to separate it the easier from the Testicle: A Servant lifts the Intestine, and pulls it gently with his Hands towards the Pubis, whilst the Surgeon pulls lightly the Te­sticle with his Hand, to have the liberty to break with the Fleam, or point of the Bistory, the Membranous ties, observing alway to cut them nearer to the Testicle, [Page 83]than Intestine: If their adherance be very strong, it wou'd be better to indammage the Testicle, because it's not so necessary for Life, and the Accidents not so dan­gerous; you must alway avoid the Sper­matic Vessels, for fear the Blood trouble the Operation: Having freed the Inte­stine from the Testicle, you introduce your hollow Probe between the Cutis and Intestine, and cut without fear to the ring of the Muscle, where consequently you are obliged to give way by a new In­cision, to disengage the Intestine from the Strangulation, in case there be any. You pass the third time the hollow Probe be­tween the Ring and Intestine, stirring it a little to be certain that the Gut be no way engaged, and slip a crooked Bistory into the hollowness, and you cut from the ring about two Lines, and a Portion of the skin, avoiding a little branch of an Arte [...]y, which runs by the Aponeurosis of this Muscle.

When you free the Intestine by the di­lation, you pull it out a little for to dis­engage it from the internal rings, and give liberty to the excrements which it contains to spread themselves; by this means it grows less tumid, and extended so, that the reduction of it is much more easie; you do it with your two Fore fingers, [Page 84]and press not the Intestine too much, lest you bruise it: Being reduc'd, a Servant must press with his Hands the Neighbour­ing parts, to hinder its falling out again: Some make several little Incisions on the Circle of the Ring, all along the Purse, which makes it incarn, and cicatrize stronger; others content themselves to introduce into the Rings a thick Tent of Lint tied with a wax'd Thread, and a length proportionable to the depth of the Wound, to bruise them as it were, and excite a speedy suppuration; some apply them dry, and others dip in some digestive, according to the pain which is felt, or humidity which relaxes these parts. But the true method to hinder this Disease from relapsing is, to introduce into the Wound, a long Tent of Lint, which re­fists the impulsion of the Intestine, which alway endeavours to dilate the rings, and so often makes the Operation unsuccess­ful. A Servant holds it on whilst the Surgeon applies the rest of the Apparatus, especially, good defensitives which op­pose Fluxions that may happen.

There are several Practitioners, who wou'd, that at the same time the Testicle be cut off; but this method is not appro­ved of, because it contributes not to the cure of the Hernia, but rather, as Experi­ence [Page 85]demonstrate, prolongs the Operati­on, makes the Patient suffer without ne­cessity, and deprives him of the proper means of Propagation; but if even the Testicles should be alter'd, so that they cou'd not be secur'd, 'twould be always more advantageous to defer the Operati­on till the Fluxion be a little moderated. If the Omentum be in the part, and al­tered, you make the Ligature in the sound part, and take off the corrupted: It may be avoided, if the tumor be recent, and preserv'd in its natural State; if it be strongly fastned to the Gut, you must if possible reduce them together, provided there appear no sign of mortification. Whether it has contracted any tie with the Intestine Testicle, rings of the Mus­cle, or with the productions which in­clude the Spermatic Vessels: 'Tis alway better to take away some of its Substance, than of the Substance of any of these parts, if necessity compel you to it. Yet I own, if it should at all adhere to the Sack that contains the Intestine, provided it be sound, 'twou'd be better to hurt the Purse than Epiploon. But as it cannot remain long in that condition without being alte­red, we are alway forc'd to cut a great Portion of it: You must take care in ma­king the Ligature, that you don't straiten [Page 86]the part too much, because 'tis of a loose texture, spongy, and easie to be cut. You pass the Thread several times all about slightly, straitning it after having pass'd the Needle through its Substance.

In the Operation of the Bubonocele, you make not so great an Aperture, but make it according to the extension, and bigness of the tumor. Concerning the rest, you follow the same Rules, and observe the same circumstances formerly mentioned.

When you have discovered the Purse which makes the Hernia, you tear it to pieces dexterously with your Nails, or the Fleam, and if instead of the Intestine you find water, be not surpriz'd with the supposal that you have hurt the Intestine, but take Courage, and remember only the signs of which we have spoken, which will fortifie you, and put you into a con­dition successfully to perform the Opera­tion; for 'tis only the Purse which is full of waters, in which the intestine floats: These waters are furnished by the Glands of the internal surface of the Peritonaeum; and by those of the Intestines, or by the eruption of some. Lymphatic Vessels: These are, if I mistake not, most of the particulars which this Operation contains; after having Embrocated with Oyl of Roses, you must apply good defensitives [Page 87]over the part and Hypogastrick region, with good compress moistned in Oxy­crate, and sustain the applications with the simple Spica; in all these affects, you must alway ease the Purses by a Suspensorium, and prefer Clysters be­fore other general Medicines.

CHAP. XII. Of Castration, occasion'd by Sarcocele, and Varicocele.

THis Operation is not alway to be Practis'd, unless other methods prove ineffectual: In the four follow­ing cases, I suppose it necessary.VVhen the Operation must be per­form'd.

• 1. When it's so closely fastned to the Intestine, that one is forc'd to take much of its Substance off.
• The 2. is in contusion, when the Vessels and Vesicles are crush­ed together, and the course of the Blood interrupted, which is known by the blackness of the Testicle, and mor­tification which follows soon after, if the progress of this commotion be not hindred.
• The 3. is, when the Testi­cle is varicous, and the virulent Hu­mours which cause the tension and di­latation [Page 88]of the Vessels can't by Me­dicines be resolved; this case is not so pressing as the others, unless the Patient be resolv'd to endure the Operation.
• The 4. is in all old Excrescencies.

To have an Idea of their generation, you must consider that the one attacks the Substance it self, and the other its Tunicles, after this you must look upon the Spermatic Arteries, as the true source and channels which convey the Matter, of which the Carnosities are form'd, and that the Arterial Blood, furnishing the Testicles with the Matter of Seed, to be prepared there, lets slip in this Ela­boration, its most greasie and viscous part, which the moderate heat that we find there condenses in the little chan­nels which compose them, or in their Tunicles, almost as the white of an Egg hardens over a moderate Fire: This Matter coming to swell and ex­tend these little tender Pipes, produces that which we call a spongy and car­cinomatous Excrescence. It's only a swelling of these little Filaments, which a strange Humour forces to rise in a tu­mor. You may also observe, that by the over-growing of a new Matter, it becomes very often so remarkable, that [Page 89]one can't long carry this burthen, with­out discharging it: If it happen that by what cause soever this Liquor should be determinated, rather into the Mem­branes of the Testicle, than any where else, and that there's form'd a Carcino­matous Substance all along the produ­ctions of the Peritonaeum, which en­croaches sometimes upon the Interior parts of the Belly; I suppose, that the Operation will then be needless, be­cause this carnosity occupying not only the vaginal Tunicle, which is a dilata­tion of the productions of the Perito­naeum, but also the productions them­selves; you would ruin the. Vessels, Rings, and several parts included in the Hypogastrium.

I will not repeat here the signs of this Disease, as for its Prognosticks,Progno­stick. they are always very bad, because it costs the Testicles, if any carnosity possess its Substance, for it can't be consum'd without destroying it, and the sarest way is the Operation.

CHAP. XIII. Of Castration.

THE Patient being laid on his Back, the Surgeon Incises with a very sharp Instrument, the Membranes of the Scrotum upon the Body of the Te­sticle, to discover the carnosity, which must be separated from the Dartos, without offending the cover of the se­minal Vessels; being freed from the Neighbouring parts, you make the li­gature of the Vessels between the Rings and the tumor; you must cut them half the length of a Finger from the ligature, and take away the Testicle with the Sarcoma; you leave an end of the Thread out of the Wound (a­voiding to pull the Spermatick Vessels to you,The Sper­matick Vessels not to be tied too hard. or compress them too hard, lest the Patient shou'd fall into a Con­vulsion) that they may not slip in­to the Belly where they wou'd shed Blood, and so cause Death in a little time: If the tumor be considerable, scirrhous, inflam'd, painful, and pos­fess both the Testicles; and of conti­nuance, the Operation is very danger­ous.

If the productions of the Peritonae­um be carcinomatous, and you have a design to make the Operation, you must first consume the Flesh by the help of potential cauteries, or molifie them by a powerful suppuration, yet it must be avoided if the tumor ex­tend it self into the cavity of the Bel­ly, for the reasons before mentioned. When the superfluous Flesh is consum'd, and the Eschar fallen, if the Vessel be preserved, you make the ligature by the Rings of the Muscles, and take away the Testicle, as I have said; for should you make it before the fall of the Eschar, the Patient would suffer dangerous Convulsions. You fill the Wound afterwards with Dossils dip'd in some digestive, and emborate, and apply defensitives, compresses, with a suspensorium, or­dering Bleeding, Clysters, and other general Remedies.

CHAP. XIV. Of Hydrocele.

A Hydro­cele from Ascites in­curable. Ʋnless you cure the Ascites.IF the Hydrocele be the consequence of the Dropsie Ascites the Opera­tion is useless, because there runs alway new Matter, which presently produces another Hydrocele, so that unless you dry up the source, there's no hopes of cure: In this the waters occupy alway the tunica vaginalis, and run from the capacity of the Abdomen through the prolongations of the Pe­ritonaeum. All other sorts of Hydro­cele proceed from the slow motion of the Blood,Other cures. or its dissolution: Falls and Blows may also contribute to their Formation: The reason is, that the Blood Stagnates more easily in these parts, which causes the serosity to separate from it on the same principle, I say, that the circumvolutions and serpentine turns, which the Spermatick Veins form in their Root, are for the most part the cause of it, if the Blood be the least dispos'd to it, for seeing it doth not circulate here, but with much ado, [Page 93]the serosities have time enough to se­parate and distil into the Purses.

Having examined the signs of the two sorts of Hydrocele, when we spoke of those of the Hernia Intestina­lis, we'll say nothing more of them than the Prognostick, which is on­ly of ill consequence when the wa­ters are included in a Cystis.

We must now examine all the circumstances of both kinds, which require two different ways of Ope­rating: We have observ'd, when we Treated of the signs, that the first kind of Hydrocele, is distinguished and known, when the waters extra­ordinarily swell and extend the Mem­branes of the Scrotum.

CHAP. XV. Of the Operation of Hydrocele.

THis Operation consists in making a puncture into the Scrotum with the Trocher, accompanied with its Canula, through which the water runs freely, and when 'tis emptied, you withdraw your Instrument, and the Cutis of the Cods becomes ru­gous as before, and the aperture stops exactly. This is performed without trouble or danger, but omit not drying up the source by the use of general Remedies, otherwise the tu­mor will not fail to return.

The second kind of Hydrocele, which generally possesses only one side, ordinarily attacks the Tunicles of the Testicle. It's also much more painful through the great tension of its Membranes.

The method of the Ope­ration.The method requir'd in this, con­sists in making the aperture deep and large enough, as well to give vent to the water, as to carry Medicines thither, which have the Virtue of dis­sipating the Membranes that are im­bued [Page 95]with them; we use to make the aperture at the side of the Scro­tum with a Lancet,The Caustic better then a Lancet. or a Potential cautery, to avoid the Spermatick Ves­sels, and seeing the cautery makes a great Eschar, 'tis to be preferr'd be­fore the Lancet, because you are in less danger of offending the Testicle, and you dissipate insensibly the Mem­branes by Suppuration.

You must Note, That seeing the Waters hinder the action of this Re­medy, in blunting its corrosive Par­ticles, if the first that is apply'd makes not an Eschar deep enough, it's ne­cessary to apply another, when the Eschar is off, you fill the Wound with Dossils, and leave those which cover the bottom four or five days, before you take them out; to the end, that by their stay, the Matter which is stop'd become more sharp, and that they may dissolve more ea­sily the Tunicles which contain the Waters; you suppurate it and dress it as an ordinary Wound.

Before you go further, you must also observe, that if the waters grow sharp and corrosive, or rather lixivi­ous, they change often into Pus, which [Page 96]makes the Testicle alter and corrupt, so that you are forc'd to take it out.

Cure of Pneumato­cele.As for Pneumatocele you must use the bandage, and all the carminative Remedies, as well internal as exter­nal; and as it's a part of the Surge­on's prudence, to order them accor­ding to his Knowledge; I shou'd be ridiculous, if I should boast here of Remedies which Authors are full of.

CHAP. XVI. Of the Phymosis.

What Phy­mosis is.THE Phymosis is nothing else but a shrivelling, and contra­ction of the extremity of the Pre­puce, which compresses so hard the Glans, that if you don't give it Air by way of Incision, it becomes in­flam'd, and often mortifies.

This incommodity is either natu­ral or accidental, the natural comes from the parts being yet concentred, and as it were, retir'd into its Tuni­cle, and that one has not yet betaken [Page 97]himself to any exercise or touching: The Prepuce forms in this affect wrinkles which are like so many little Bolsters,As Venery. between which gathers and stagnates a tenacious Matter, sepa­rated by the Glans with which the inner surface of the Prepuce is sprink­led, which thickens by the heat, and growing impure by its stay, there is as it were a kind of Glew which fa­stens the Prepuce to the Glands, and so straitly presses it, that it will not let the Urin flow.

The Surgeon therefore first endea­vours to free the parts, pulling to him the extremity of the Prepuce, then introduces at the side of the Virga an Incision knife between the Glands and Cutis, piercing the Pre­puce without danger, and cuting all between the Instrument and Extremi­ty of the Glans: If one Incision be not enough to discover it, you may bold­ly make another on the opposite side, the sole motion of the parts being capable to extend the Fibres of the Prepuce, and render them obedient, and make them that they restrain and dilate themselves according to thene­cessity of Nature.

You must not use this Operation till you have tried Fomentations,Caution. E­mollent injections, and all other Re­medies in vain; which method is to be observ'd in all Operations.

The second kind of Phymosis is caus'd by some Inflamation, Shan­ker, Ulcer, Induration, Callosity, and often by irritative Remedies mis­applied; in all these cases, whether the sharp Humour which comes from the Ulcers, irritate the parts, or cor­rosive Medicines, it happens that the passage of the Blood and Spirits is hindred, and the Inflamation be­comes so considerable, that the Fi­bres are no more in a condition to obey: This is also the reason why this virulent Sanies which comes from the Shanker, excoriates these parts, excites sharp pains, felt only at the extremity of the Yard, and Infla­mation, which is soon followed by a Gangreen, if you hinder not its progress.

Cause of Pulsation in the part.The pulsisick pain which is felt in this part can't proceed but from the Glans which is covered with a thin and delicate Membrane, hume­cted by a great number of Vessels, [Page 99]particularly of Nerves, and that its Substance is of a very fine and sen­sible texture; so the motion which these virulent Matters imprint on the Spirits, not being able to commu­nicate themselves to the rest of the Yard, because of the force and thick­ness of the coverings of the caver­nous Bodies, the pain must needs aug­ment and become much more sensible and acute in this part.

But before you resolve on the Ope­ration, use Bleeding, Fomentations, Suppurations mixt with some prepa­tions of Mercury, which you must introduce with the end of your Probe, the cerot of GALEN Emollient injections, a Ball of Lint put between the Glans and skin, compresses wet in Oxycrate; in a word, all these Remedies must be apply'd, but es­pecially the Situation of the Virga, which must be laid on the Belly, and sustain'd with a little Bandage.

CHAP. XVII. Of Paraphymosis.

VVhat Pa­raphymosis is. PAraphymosis is a Disease quite con­trary to a Phymosis, in one, the Glans being hidden, in the other, Strangled, and so strip'd of its Pre­puce, that you can't cover it again.

The cause of this Strangulation comes sometimes from the over­throw of the Cutis,Cause. which forms a sort of Bolster, and sometimes from Inflamation, which a Shanker or some other tumor preceded; if the Strangulation be considerable, there must needs follow interruption of the course of Blood and Spirits in these parts, and consequently a mor­tification: In this affect the Yard-swells so hard, that it forms three or four Bags, as it were alternately dispos'd half a Finger's breadth one from another: These pursings come partly from the obstructions, and partly from the reflux of Blood and Spirits in the Body of the Virga, they are commonly follow'd by a tumor which occupies the neck of [Page 101]the prepuce, and which is full of a reddish water, which by the great heat of the part so rarifies ordinari­ly, that from an Aqueous it becomes Windy.

This tumor augments so consider­ably the Inflamation, that if you don't scarifie deep the tumified places to give a discharge, the Penis wou'd not fail to mortifie.

How to bring over the Pre­puce.You must endeavour to reduce the Prepuce without compressing the Glans, or putting your Thumb on its extremities, as most do that treat of this Disease.

The Reason is, that when the ex­tremity of the Glans is pressed, it enlarges it self, and swells more, which instead of making the prepuce slip, rather folds up, and hinders its reduction.

You use almost the same Remedies as in Phymosis. There be some that pour cold water on the Belly, but I think it of no great use, or at least see no great effects of it; for want of these Remedies, you may use in Inflamati­on some Styptick water, in which, dip your compresses, and apply them about the part, you must also keep [Page 102]the same Situation and Bandage as in Phymosis.

CHAP. XVIII. Of the Stone and Lithotomy.

THe STONE with which Man­kind of all other Animals is most troubled, is called in Latin, Calculus, Name. and those affected with it, Calculosi: Its origin wou'd have been always unknown to us, if the Chy­mists Art had not discover'd to us the secret of its formation, in shew­ing the principles which Compose it by the just Analysis that Science makes of it.

The Opinion of the Anci­ents con­cerning its formation.All the Ancients and their Abet­tors have alway maintain'd with great heat, that the Stone is form'd by the most Crass, Course, and vis­cous particles of Blood, which being carried into the Bladder with the Urine, came to be the Matter of the Stone.

Of Hypoc­rates. Hypocrates imagined, that the Stone was form'd by the Urines retention in the Bladder, and that the most [Page 103]gross and terrestrious Particles stop'd there, and stuck to the bottom al­most in the same manner as the Gra­vel gathers in the bottom of a pot, where the Urin has been long re­tain'd, and that certain slimy Par­ticles gather there, which serve for a tie to the little Gravels there as­sembled, and that after this manner, by the overgrowing of a new Mat­ter, the Stone becomes insensibly bigger.

This Opinion is more probable than solid; for it's evident, if the Stones were form'd after Hipocrates's way, supposing the principles which he admits, 'twould doubtless not have consistence strong enough to resist the Hammer as this doth, it's much more reasonable to believe, that what we see in the Urinal of those thus Diseas'd, is nothing else but the Volatil Spirit of Urin, which taking its flight, sticks rather to the sides of the Urinal than bottom, as experience demonstrates.

The Opinion of Ferneli­us. Fernelius pretends, that all the Stones which are found in the Blad­den fall from the Reins by Nephri­tical pains, and says, That if the Gravel which passes from the Reins [Page 104]into the Bladder, be of any consi­derable bigness, and that it lies there for some time, the Stone is form'd there, which grows bigger and big­ger by the access of new Matter which comes to it without inter­mission: And that which fully per­swaded him to believe, that Ne­phritick pains excited the Gravel to fall from the Kidneys into the Bladder, was, That he never found any one troubled with the Stone, but some Nephritick pain went be­fore.

He says also, That when you break the Stones which are wholly form'd, you find in the middle a little Ker­nel, which has a covering different in Colour, and Substance from the rest of the Stone, and whose Figure perfectly imitates the Pelvis of the Kidneys, from whence he concludes the Stone is formed in it, before it falls into the Bladder.

Fernelius wanted nothing more than the knowledge of the principles of the Stone, to have had a perfect Idea of it: And what made him fall into this Error, after Hipocrates was, That he founded himself on [Page 105]that old Maxim of the Ancients, that Stones are formed by the terre­strial and gross particles of the Blood, which disengaging themselves from the others, and uniting together, form Calcules.

The only reason which they give for it, is, that these Gravels are ve­ry firm and massy, and that such Bodies can't be fram'd, but by the assembling of that which is most irregular, and heavy in the Blood. They pretend also, that we must conceive this generation to be like the gross and massy Bodies which are made on the Earth, to which the formation of the Stone in Man's Body has a great deal of Analogy: All Minerals having no other prin­ciples than the most inflexible and weighty Particles of the Earth: But this is a prejudice grounded only on the impression and con­fus'd Ideas of the Senses.

Reason and Experience are their opposites, for this latter shews, that the Volatile Spirits, and most sub­tle Bodies frame by their mixture a heavy and solid Body; which the sixt Salts, and other grosser Bodies, [Page 106]more incapable of motion cannot do, as Chymistry Demonstrates: Nay, Reason convinces us of it, for it's easily conceiv'd, that the grosser and more irregular Particles cannot adjust, or restrain so well, or press themselves with so much strength, as the more fine and regu­lar, in order to the framing a solid and compleat Body.

Two essenti­al princi­ples to­wards the generation of the Stone. Chymistry discovers to us two essen­tial principles in the Urin, by the Analysis which it has made of it.

The one is a Urinous and Vola­til Salt, which much resembles the Spirit of Nitre: And the other a ve­ry Aethereal Sulphur, which is like Spirit of Wine.

Experience Demonstrates,Experi­ment. that if we mix Spirit of Wine with Spirit of Nitre, a coagulum is presently form'd, but these two principles be­ing engaged in the Urine, and it's course not permitting them to Unite together to form the Stone.

Van Hel­mont's O­pinion.The Urine, as Van Helmont says, must fall into some disorder before the Stone be form'd, and although the essential principles of the Gra­vel, in which consists the Seed of the [Page 109]Stone, be in the Urine, it needs an intermedium or ferment to excite and cause the Seed to germinate like as in other generations, there­fore 'tis a corruptive ferment, says Van Holmont, which is sometimes in­gendered in the Urine, and which awakes and vivifies the principles of putrefaction, which uniting them­selves intimately form the Stone in the midst of the Kidneys.

This is the manner this Author proves it, and we may say to his Credit, that of all who have writ­ten on this Subject, none has done better than he.

He says, there's no Transmuta­tive Principle in Nature without Ferment: The Urine does not cor­rupt in us, because of its motion; but there must needs be found in it a corruptive Ferment, by occasi­on of which, 'tis apt for Putrefa­ction; so that the Putrefaction is not made by the Urin's being vi­tiated, but the Reins Suscitate the vitious Ferment to the generation of this strange Body: And he sup­poses, that 'tis the smell alone of the principle of Putrefaction which stirs [Page 110]up, and separates in Heterogeneal parts, that which before seem'd to be Homogeneal; like as the smell of a Vessel, wherein there has been some acidity coagulates and sowers Milk,The Fer­ment of the Stone con­sists in a smell only. or as the smell of Leven Fer­ments, and infects the Dough, and the smell of a musty Fat, corrupts and Ferments the Wine, even so in the Urine does the Ferment, which disposes to the Gravel, consist in a pure smell only.

It's also observ'd, that the Urin putrifies sooner in a stinking Vessel, in which Urin has been kept a long time, than in one which is clean and new.

He supposes, that the coagulation of the Stone is made in an instant, though its growth is made by de­grees, and sometimes all at once.

In the Distillation which he has made of the Urin, he has always found therein a Spirit of Nitre, which he calls a coagulating Spirit, associa­ted with the Spirit of Wine, and though they be both very volatil, they coagulate, as Spirit of Vitriol mix'd with Sal Armoniac, which eva­porates also very easily.

Besides this coagulating Spirit, and the Spirit of Wine which meet to­gether in the Urin, he says, there is also found in it a terrestrial Styptick Spirit, which by the means of pu­trefaction becomes volatil, so that this Spirit of Urine, drinking up the terrestrial Spirit, excited by a putrid Ferment, suscitates the Spi­rit of Wine which is in repose, and concentred in the Urine, which mingling intimately together, and acting one with another, by a re­ciprocal action, condenses in the middle of the Urine, and forms a stony Matter.

The good or bad use of Food, contributes much to its formation; we observe, that those who use too spiritous Drinks, and dirty Food are more subject to it than others. We see also, that those who live on Milk Meats, Fruit, Pulse, Rye bread, and several other Impurities, are of­ten tormented with it: The latter contribute to it, because of their Im­purity, and the other by reason of their spiritous Particles, the latter fur­nish the principles of the Stone, and the other the Ferment, which dis­poses [...] [Page 112] [...] [Page 113] [...] [Page 102]the Excrements, because working on the Colon, which is near, it gnaws and corrodes the Tunicles, and after this manner opens a passage to come out this way. Vomiting, and Palsy of the Thigh and Leg, are also concomitant; the Diseased can't stand strait, and the Testicle of the same side retires in­to the Groin.Cause of Vomiting in Inflama­tion of the Reins. The Vomiting proceeds from the mutual communication that is between the Nerves of the Kidneys and Stomach, by the Irritation of the Spirits in the carnous fibres of the Sto­mach, occasioned by the Inflammation of the Reins.

Cause of the Palsy of the Thigh, &c. in Inflama­tion of the Reins.To give a reason for the Palsy, you must observe that the Kidney is laid upon the head of the Muscle Psoas, which it presses and inflames; this Muscle being inflamed, also presses a thick string of Nerves which passes through its body, and distributes it self into the interior part of the Thigh and Leg, from whence follows the stu­por, by the suppression or obstruction of the Spirits. After this manner the Muscle Psoas reciprocally inflames the Iliac to which it's join'd; and seeing these two Muscles serve to bend the Thigh, it can no more obey not follow [Page 103]the action of these Extensors, which is the cause that we can't stand upright without cruel pain.

Cause of the con­traction or shriveling up of the Testicle into the Groin.The Testicle retires into the Groin, by reason the Iliac Muscle is join'd to the Cremaster's, which embraces the body of the Testicle, so that its fibres being shortned by the Inflamation, (which the Iliac communicates to it) the Testicle must necessarily mount into the Groin; nevertheless all these Signs are equivocal, seeing they may hap­pen in the ordinary Inflamation of the Reins, that is to say, in the Nephretic Colic.

Signs of the Stone in the Bladder.The Signs of the Stone in the Blad­der, are palsific burning pains in the time of making Water, the Urine comes out by drops and reiterated turns, as in Stranguria; and as the Bladder is emptied and diminished in bigness, its sides apply themselves so hard against the surface of the Stone, which if it be rough, it fails not to cause sufficient convulsions, and break some vessels, in which consists the burn­ing pain one feels after pissing, and the last drops are often bloody.

The Water is made by turns, because the Stone which lies heavy on the neck [Page 104]of the Bladder,Causes of these Signs of the Stone in the Blad­der. stops partly the passage of the Urine; but the worst is, that in the time of pissing, and when the sides (which before were extended) come to touch rudely against this rough bo­dy, its nervous fibres break, and gives way to the Urine, by its acrimony to prick them, so causes convulsions, cruel and pungent pains, and imprints on the spirits an irregular motion, by oc­casion of which the carnous fibres con­tract and embrace the Stone faster, the diseased thinking in that moment to ease himself, and desiring to suspend the course of the spirits, augments on the contrary the violence of the pain, and retards the course of the U­rine, and so causes some of it to re­main always in the Bladder, which grows acid, and at length becomes stinking by its stay there, so re­news much sharper and insupportable pains.

Cause of Itching.One feels an Itching in the region of the Perineum, which irritating the sphincter of the Anus, excites a Tenes­mus; the Itching continues even to the extremity of the Gland, which obliges the Patient to rub it often.

Cause of Heaviness about the Perineum.The Heaviness about the Perineum can't proceed but from the weight of the Stone, and the itching from the acrimony of the Urinc. Sometimes there happens a Priapism, or an invo­luntary erection of the Penis, caus'd by the irritation of the fibres, and infla­mation of the bladder and urethra, which communicates it self to the ca­vernous bodies; It's easy to see that the irritation of the part (join'd with some slight indisposition) can awake and hasten the course of the blood and spirits design'd for the functions of the Yard, and adjacent muscles, which be­ing swell'd by the spirits, compress the veins which are distributed in it, to hinder the return of the blood; the blood and spirits filling all the vacuum, or empty spaces of the hollow bodies; the Yard must needs grow stiff, and extend it self.

We observe that the Urine is some­times white, sometimes bloody, trou­bled and muddy, and is charged with a mucous and sandy sediment.

HIPPOCRATES in his Apho­risms reports, That when the Urine is extreme clear, and you find Sand in the bottom of the Urinal, it's an infal­lible [Page 106]mark of the Stone's existence in the bladder.A certain Sign of two or more Stones in the Blad­der. When the Stone is smooth, it's a sign that it's accompa­nied with some other Stones, which by their continual atrition become po­lished and smooth. If the Stone be big, and lies heavy on the neck of the bladder, it dilates in such a manner, that in time it grows as big as its bot­tom. If it adhere to any part, or is contain'd in a cistis, the Patient may carry it all his life without any detri­ment, or manifesting any of the signs which we have spoken of, especially when it's suspended at the bottom of the bladder.

An Obser­vation. VAN HELMONT assures us, that he knew a Priest, who going to reach a Book in his Library, at the same moment felt a great weight in the Hypogastric Region, which was presently followed with all the Sym­ptoms we have describ'd, 'twas the Stone which was then separated from the bottom of the bladder, (by this simple effort) so that he was obliged to come to the operation; but the most sure and certain sign of the Stone is the Probe, which convinces us of it, by the resistance it makes, and noise which [Page 107]we hear when we strike upon it; this is also the sign which causes the necessi­ty of the operation, if the age, season and strength of the Patient permit.

No Medi­cine so pow­erful as to dissolve the Stone.Here it is where Mountebanks tri­umph, who, by their Impostures, en­deavour to persuade People that they have infallible Secrets to dissolve the Stone in the Reins and Bladder; these sweet hopes flatter the minds of those who are troubled with it; but when we shew them by evident demonstra­tion, that the most violent and caustie Acids, as Aq. Fortis, Spirit. Nitri, &c. cannot dissolve it, we make them know also, that if ever these Impostors had any Medicines capable to produce such Effects, without altering any part before they were past the Stomach, In­testines, Receptacle of the Chile, Heart, Lungs, and in the most insensible ways where they mingle with the Blood and Humors, they would doubtless lose their quality and dissolving vertue; therefore there's nothing can free us from such a cruel Disease but the ope­ration,Nothing can free us of the Stone but the opera­tion. after having used general Re­medies, as Bleeding, gentle Purging, and Clysters, unless the Stone be of an [Page 108]extraordinary bigness, and there be a complication of Diseases.

If the Stone be of a moderate big­ness,Prognostics. the operation is less dangerous; if 'tis big, and stick in the bladder, it's more to be fear'd, because of the rup­tion of the vessels, and of the great laceration it causes to the parts, which is always accompanied with Inflama­tion, Convulsion, Fever, Gangrene, and often Death; especially in young, who are not over Nine years of age, and whose parts are soft and tender; or in old, whose parts are dri'd up, and inflexible as it were, through the little heat and humidity which we find in them.

If the Bladder be ulcerated, and there be any great Hemorrhage, or some Carnosity, you must avoid the opera­tion, all these Particularities belong to the Prognostics of the Disease; you must observe that these sorts of Subjects often relapse, and if the operation were not reiterated, you would find a Quarry in their Bladder.

CHAP. XIX. Of the Extraction of the Stone.

HAving thus consider'd the prece­dent Circumstances, you may hazard the Operation; but before, it's necessary to stir the Stone by some mo­tion, and to empty the Bladder of its Urine.

The scitua­tion of the Patient in the opera­tion.Place the Patient on the brink of a Bed, his back on an even sloaping board, his thighs open, knees near his belly, his heels drawn up to his brich, and his hands hanging down on the sides of his ankles.

To keep the Patient in this posture, you have a band with which you sup­port the thigh, lower end of the leg and hand, and after some turns of the band, you pass it upwards about the shoulder, and slipping it behind the back, you repass it about the other should, to bind the hand; leg and thigh of the opposite side: this po­sture is very proper to execute this de­sign; for it upholds the bladder, and gives liberty to the muscles of the Ab­domen [Page 110]to relax and bend, as they for­merly did.

The manner of cutting for the Stone by the Apara­tus minor, or Gripe.The Patient being in this posture, the Chirurgion disposes himself to the operation; if it's by the little Apara­tus, (which is not so much in use) he wetts his Index and middle finger in some oil, or other unctious matter, and introduces them a little obliquely into the Anus, not stretching them, till he has prest gently the Hypogastrium with the other hand, then the Operator en­deavours to push the bottom of the bladder towards its neck, to place it faster between his fingers, and the Os Pubis; having fixt it, the Chirurgion with a Bistory cutting on both sides, makes an Incision on the Stone accord­ing to its bigness,The Place where the Incision must be made. on the side of the Ra­phe, and between the os pubis, about two fingers breadth from the Anus. The Incision being made, you extract it with fitting Instruments, of which ☞ we'll speak in the Great Aparatus; sometimes it will slip out of the Orifice, by only pressing the fingers a little for­wards towards the Orifice: so much for the lesser Aparatus; for seeing we can't use it without making the Intestine and Bladder very livid, nor often without [Page 111]endamaging them, we ought to reject this method, and prefer the Great Aparatus, of which we will give the description.

The manner of cutting for the Stone by the Great Aparatus.After we have regulated all that pre­cedes this so important an Operation, and having plac'd the Patient in a con­venient posture, the first thing we must propose to our selves is to search him well.

Several ways of using the Catheter.As for Probes, you ought to have some great, small, and middle-sized ones, for all sorts of Ages; strait and crooked for both Sexes, with canulas garnished with a stillett, to empty the bladder of the urine, and others hol­low, as a Directory to perform the Operation with; you may use the Prob [...]or Catheter divers ways.

In the first, the Chirurgion takes with his left hand the top of the Yard, (dilating its passage a little) and pulls it upwards, that the chanel of the urethra make a strait line, to facilitate by that means the entry of the Cathe­ter into the bladder; all the difficulty consists in introducing it methodically, which is, that the extremity which is held in the hand be outward, and the convexity inward; and as its point [Page 112]approaches towards the neck of the bladder, you give it half a turn, by which means you make it slip under the Os Pubis, and cause it to enter into the hollow of the bladder, so that its point is within, and its convexity with­out.

Second way of Probing.The second method is much more easy, and less troublesom, because you introduce the Probe quite contrary to the former; and without giving it a turn, you make it slip into the blad­der.

Good Probing is not only necessary for extracting the Stone, but also in all carnosities and inflamations of the bladder; it's of great use as often as the Urine is supprest in this passages, and very often one perishes in all those occasions, for not knowing how to probe well.

How to per­form the operation methodi­cally.To make the Operation, you use a hollow Probe, which being in the blad­der, the Chirurgion must bring it to the side of the belly, that its convexity may press the interior surface of the Perineum, and make it rise in a hillock, and whilst the Servant holds up the Yard, and top of the Probe with his left hand, and the Testicles with his [Page 113]right, the Operator, with his thumb and forefinger, fastens the most emi­nent part of the Probe to the right side of the Perineum, and with a Knife cut­ting on both sides, he makes an In­cision all along the hollow, more or less great, according as he judges the bulk of the Stone to be. To make the Incision regularly, he holds the In­strument like a Lancet, beginning to pierce the most elevated part of the Perineum still to the hollow of the Probe, which serves to the Knife as a Directory, and without any stop pass and repass it several times over the surface of the Probe, till it be quite discover'd, lest you make divers Incisi­ons on the bladder. Before you with­draw the Catheter, feel with your finger, to know whether there remain any adherence which might hinder the en­try of the Conductor, introduce its extremity into the hollow of the Probe as low as possible, the Conductor be­ing as it were engaged in the Probe, as you withdraw it softly out of the bladder, you push your Conductor, and make it follow the motion of the Probe, otherwise it might escape side­ways, and the Operation would not [Page 114]succeed with the success one would desire; when you'r sure that the Con­ductor is in the capacity of the blad­der, you slip over its surface strait or crooked pincers, then withdraw your Conductor, and search dexterously for the Stone on all sides without violence; then take hold of it; if it's fastned or sticks, you turn softly your hand on both sides to break the ties which hold it, without causing Contusion or Haemorrhagy.

What's to be done when it sticks to the bladder.If the Stone strongly adhere, you must not offend the bladder, but move it moderately; if your ties be too strong, you must use the toothed crow's-bill or incisive pincers, always taking care lest you offend the bladder.

When the Stone happens to be too big, enlarge the Wound with the Bi­story, and reject the use of the Di­latorium, by reason of the great Con­tusions it commonly leaves in the parts.

What's to be done when any urgent Symptoms happen in time of the Operation.If any Accident should happen in the time of the Operation, as Haemor­rhagy, Syncope, or any other trouble­som Symptom, the Chyrurgion ought rather to correct them, than finish the Operation, and so leave the Patient in [Page 115]repose, till he has got new strength, and the Accidents are ceased; for ha­ving [...]eferr'd the Operation after this manner, the Stone very often pre­sents it self at the orifice, and the Cure is much more easy and success­ful.

When the Stone is extremely smooth, 'tis a sign that it's not alone; then search, and being convinc'd, you extract them with the Pincers. If the Patient has violent pain, use Injecti­ons of milk, or other Anodines; when the Stone is rough and unequal, and signs of Excoriation appear, use De­te [...]ves made of Whey, Decoct. Hord. Plantag. cum Syrup. de Rosar. Sicc. & similia.

If the Scrotum be livid, and there be sign of mortification, make use of the most violent Resolutives and Defensi­tives; when the Stone is extracted, put in the Spoon, to cleanse it from the gravel and grumous blood which might be there, lest by any stay it might cause some disorder: Having discharg'd the Bladder of these strange bodies, if the orifice be over-large, you may make some stitches, and leave a space to put a little tent of lint in, [Page 116](tied with a thread) in case you suspect that there might yet [...] any clods of blood, or some relicks of the Stone;Tents of Lead or Silver not to be used. never use those tents chanel'd with Lead or Silver; for their contex­ture being too close, cannot soak in, or imbibe any particles of the sharp juice, which ordinarily runs from the lips of the wound; and since we know that the calosity of any Ulcer depends only on the action of a saline and pungent liquor, as we shall prove, when we speak of Fistula's, we must not be astonished that the wounds where these kind of tents are introduced, degene­rate always into a fistulous Ulcer; whereas the Lint, whose contexture is very spongy and loose, soak up, and charges it self with the points of the Salts and Acids, so by this means hin­ders a wound from growing callous: But if you'r sure that there is no strange body, the use of tents is abso­lutely needless; you only apply some boulsters, plaister, compresses, and the bandage, after that you dress the wound as a simple one, and to hasten the reunion, you make the Patient lie cross-leg'd, and tie his two knees to­gether; some lay under the Patient's [Page 117]britch a little bag full of bran, to hin­der the Urine which runs out from heating or fretting the skin of the parts.

If the Urine by its weight should carry along with it some little Stone into the Ʋrethra which stops its passage, the Urine endeavouring to escape sometimes, draggeth the Stone along with it; but if its largeness doth not permit it, the stream of the Urine for­ceth it to dilate, and extend the sides of the Ʋrethra, which causeth a rup­tion of the vessels, upon which follow­eth pain and inflamation.

How to cut the Stone from the Urethra.If in this Accident you cannot get it out, place it between your fingers, and make and Incision (according to the length of the Yard) upon the body of the Stone, which you must ex­tract with a fitting Instrument, then you close the wound, by the help of an uniting bandage, and other reme­dies.

Women not so subject to the Stone as Men.It's true Women are sometimes troubled with the Stone, but not so often as Men, because they have those passages more open, not so crooked, and less long, so by this means the Urine by its stream precipitates easily [Page 118]the little gravels which gather toge­ther in the bladder, not giving the fer­ment time enough to produce its ef­fect, which is the cause that they are much less subject to it; however if the Probe, and the other signs con­vince us of its existence, you must un­dertake the Operation.

How to ex­tract the Stone in Women.The Probes which we use for Wo­men are strait, only a little crooked towards the end. If the Stone be little, you may extract it with the finger or spoon. If it be big, make a little In­cision at the upper part of the Ʋreter, to introduce the little duck's bill, to facilitate therewith the extraction. As for the suppression of Urine, and all other circumstances that regard the Operation, you have nothing to do but to imitate the method which we have formerly given.Signs of good success in the Ope­ration. I will only say, that we know the Operation to have good success, when the Patient rests well, has free respiration, tongue moist, thirst moderate; little or no pain; Fever, but moderate; no swelling in the Hy­pogastric region, and the Inflamation abates on the fifth or sixth day.

CHAP. XX. Of the Fistula in Ano.

What a Fistula is.BY a Fistula, we understand a ca­lous, deep and cavernous Ulcer, which from a narrow entrance, ends in a large and spacious bottom, yield­ing (for the most part) a sharp and virulent matter.

What parts are most subject to Fistula's.Fistula's possess indifferently all parts of the body, especially the Anus, breast, Os Lachrima, Joints, all spongy parts loaden with fat, and humected with many humours; all nervous parts, or at least such as are quite destitute of flesh and fat, from whence it comes that wounds, which penetrate to the bones, almost always degenerate into Fistula's.

If Wounds happen in spongy parts, it's easy to conceive that nothing hin­ders the humours from finding out passages, and altering various parts, which is distinguished by the colour, consistence and acrimony of the matter that flows from them, which makes all the difference of Fistula's.

Cause of Fistula's in general.The cause of Fistula's in general, almost always proceeds from a wind­ing Ulcer, which is sorm'd and nourish­ed by the most sharp and salt particles of the blood.

Causes of Fistula in Ano.The cause of those which happen to the Anus, (whose nature we are here to explain) are Internal, or External.

External Causes.The External come from some Wound, as from Leeches ill appli'd; or from some bruise, whether by ri­ding, or by some other vilanous exer­cise, as Buggery; or finally by some fall, or any other violent motion. It's evident that all these Causes must hin­der the Circulation of the Juices, and give way to Impostumation, which in a short time degenerates into a Fistula.

Internal Causes.The Internal, are ordinarily Conse­quences of Obstructions, Inflamations, Ulcers, Haemorrhoids, and Impostuma­tions.

Why the Blood is more easily obstructed here than in other parts.Now our business is, to give Reasons why the Blood stops more at this part than at any other, to produce these kind of Accidents, of which Fistula's are troublesom Consequences.

To have an Idea of it, it's necessary to examine some Circumstances which depend on the structure of the part.

The first consists in the disposition of the Intestinum Rectum, First. and in the tem­perament of its neighbouring parts.

The second regards the nature and multitude of vessels which water it,Second. and the abundance of humours which they carry along with them.

Structure, &c. of the Intesti­num Rectum.The Intestinum Rectum is every where encompassed with fat two or three fin­gers thick, especially in full and fat persons, which makes the extravasated Juices more easily penetrate these parts to attack the Gut; which is a part very subject to alteration, by reason of its great humidity, and number of vessels that enter into its substance.

The Vessels of the In­testinum Rectum.We know that the Arteries, and Hy­pogastric Veins furnish it with two branches each; the Aorta gives it one branch of an Artery which comes from that part where it's divided into the Iliac; and the inferior mesenteric Ar­tery another, besides the Hemorrhoi­dal Veins, one of which come from the splenic, and the other from the mesen­teric. It has also many limphatic ves­sels, and several glands that separate a white and viscous humour, which lines its interior surface, and defends it against the acrimony of the Excre­ments, [Page 122]and other Levens; these are the different vessels which water the Inte­stinum Rectum.

Now it's easy to understand from all I have said, that the Circulation of the Humours must be very slow in that part, because they remount against their own weight, and are deprived of the motion of the muscles, which is of great use to hasten the Circulation of all the Juices; so for any little pro­pension they have to stop, and be cor­rupted there, (if by chance any of the External Causes, which we have spoke of, contribute towards it) they never fail; if so be it comes from the Veins, to cause the Haemorrhoids; Inflama­tions, and Impostumations, if from the Arteries; and Excoriations, and Ul­cers, if from the Lymphatic Vessels and Glands. And as these parts are extreme penetrable, if the blood ac­quires any malignity or ill quality by its fermentation, nothing hinders but it opens it self a way, and finds passa­ges to attack sometimes the gut, some­times the flesh, sanguiferous vessels, nervous parts and bones; and finally, to produce the diversity of Fistula's, which we call strait, oblique, or wind­ing. [Page 123]When the Fistula is in the flesh,Signs of Fistula's in divers parts. the Pus that comes out of it is thick, muddy, course and viscous.

If it attack the nervous parts, you have pungent and violent pains, and the humour which flows from it is sharp and serous; if the matter of the Fistula move towards the sanguiferous vessels, and break any of them by its acrimony, its colour is like the wash­ings of flesh; if the Fistula penetrate to the bone, and it be altered or rot­ten, the matter which comes from it is clear, thin, and in its highest degree of acidity.

A salt and sharp juice the cause of calosity.We likewise observe, that in these kind of Fistula's, the calosity is much more considerable than in others; for as all the world knows that the calosi­ty of a Fistula depends only on the presence and action of a sharp and salt juice-like Brine, you must not be asto­nished if those that reach the bones (which are nourished with a humour that's extremely salt and pungent of its own nature) be so calous; for from the moment that the sides of an Ulcer care water'd, and humected with an humour like it, if its intemperies be not corrected, its points creep insensi­bly [Page 124]into the bottom of the Ulcer, and after several punctions, these little needles (which we must consider as so many wedges) enter, and fix them­selves so into the porosities of the flesh and membranes, that they render the Ulcer so hard and calous, that it turns into a Fistula.

As for the Prognostics of Fistula's,Prognostics. I say in general, that those which are new, which happen in a good tem­parament of body, are well condi­tioned, and that possess such parts where Medicines may be easily appli'd, are curable.

But on the contrary, if they be old, the Party Cachectical, when they pos­sess such parts as are necessary for life, as the Bladder and Intestines, uncura­ble. Lastly, all Fistula's which attack the Bones, Tendons, Arteries, Vertebra's of the Back, Breast, Belly, Paps, Axilla, Groins and Joints, are doubtless diffi­cult to overcome.

Where Pal­latives are convenient.Some Fistula's are cured by caustic Medicines, others by Iron; some, where Medicines are not able to vanquish, need only Palliatives, or such as are proper to stifle and check the violence of the effect, and prevent more trouble­som [Page 125]Accidents. Finally, there are some which reduce the parts to such a lan­guishing and deplorable condition, that they being unable to perform their or­dinary functions, we are obliged to amputate the parts, as those in the Joints, unless it be in the Axilla, or other parts where the Operation can­not be perform'd. In such dangerous Affects, we are to have no other aim, than to mollify by all means the Hu­mours which foment and nourish them; being they threaten death in all Subjects.

The Anus subject to several sorts of Fistula's.The Anus is liable to several sorts of Fistula's, whose knowledge mightily favours their Cure.

The first is, when it pierces the Bo­dy of the Intestine, and hath no out­ward Aperture.

The second openeth outwardly, and hath no communication with the In­testine, or hath only slightly touched its superficies.

The third, which is call'd complete, manifests it self both outwardly and inwardly.

The fourth is of several Burroughs, or Sinusses, which discharge themselves into a Sac, which is as the concourse of all.

Signs of the first kind of Fistula.The Signs of the first kind, are a little outward swelling, accompanied with a slight Inflamation; the matter runneth with the excrements, or after them, with pain and excoriation of the Intestine and Sphircter, Itching, Tenesmus, and Inequality of the Aper­ture.

Causes of these Signs.The swelling is caused by the ob­struction, compression, expression of the Pus, and the efforts which the ex­crements make at the passage; and if by its stay there is be grown acid, and hath contracted any malignity, it cau­seth divulsions passing over the surface of the Intestine, which excites pain and inflamation.

But on the contrary, if it stay there, hath not as yet corrupted it, and that it hath (in a manner speaking) only entred into its first state of alteration, it excites but slight divulsions, in which consists the itching.

This same matter acting upon the fibres of the Intestine, rout the spirits, which being irregularly carried into its carnous tunicle, sphincter, and musculi levatnes, the Gut is obliged to empty it self of the little excrements it con­tains.

But in the time that the carnous tunicles by its action precipitates and expels the excrements, the sphincter and levatores shut and stop so exactly the passage, by means of the irritated spirits, that they oppose their coming forth, and force them often to remount, in spite of the action of the muscles, of the Abdomen, and carnous tunicle of the Intestines, which causeth the Te­nesmus.

Signs of the second.The Signs of the second sort of Fistula, are known by the Probe, and matter which comes out of the Fistula.

Signs of the third.Those of the complete, are the same which we have related in both the foregoing Fistula's.

Signs of the fourth.The Signs of that which are with Sinusses, are pain, abundance and dif­ferent changes of the matter which flows; but the surest Sign is the Probe.

CHAP. XXI. Of the Operation of the Fistula in Ano.

IN the Operation of the Fistula in Ano, of what kind or nature so­ever it be, you always observe the same Rules and Maxims.

How to per­form the Operation.First, You place the Patient on the brink of a Bed, laying him on his belly, his legs stradled; you dispose a ban­dage about his body in shape of a T. if it be a Fistula that openeth inward­ly, you introduce, if possible, the Stylet, or Probe, through the passage of the Intestine, and slip all along the Fi­stula to the bottom; when you find with your finger the end of the Probe outwardly, make a little carved Inci­sion over it, that the end of the Probe may come out; bend it a little, and cut, not only all that the Probe embraces, but also a little under the bottom of the Fistula, that the re-union be more easy perform'd. If so you can't pass your Probe through the Intestine into the Fistula, you make the Incision [Page 129]outwardly on the Tumor, as we have prescrib'd, that the Probe may be easier introduced and passed into the In­testine.

When a Caustic is to be used.If the Tumor be somewhat distant from the brink of the Anus, you must prefer a potential Cautery before the Bistory, for to lessen the pain.

When the Operation is to be omttted.If the Fistula anticipate the breadth of four Fingers upon the body of the Gut, and that it openeth above the Levadores Ani, you must not hazard the Operation, for Reasons which we will alledge hereafter.

In the Fistula which opens outward­ly, you pass a Stilet through your A­perture, and pierce the Intestine, and make it come out of the Anus to bend it, or make a Handle, as hath been said.

Some in a Fistula make use of Scis­sers, and others of a narrow Instru­ment like a crooked Bistory, whose edge is arm'd with a sheath of Tin, you introduce it through the orifice of the Fistula, and passing it through the orifice of the Gut, you cut at one flash the whole bottom of the Fistula; if the Calosity be considerable, you sca­rify the sides and bottom: the most [Page 130]to be fear'd are the Arteries; but if by misfortune you should have cut any of them,Vitreobe's to be re­jected. you must use some stiptic water, or the ligature if you can, and reject the vitriolate Button, because of the Intestine.

The Operation being made, you introduce your fingers into the Fistula, to find if there be any adherence or sinusses, which must be loosen'd, and open'd with the Scissers, (as well to facilitate the entrance of Medicines, as to give passage to the Matter which lurks there, and which would in time serve for a new Ferment to produce new Fistula's) avoiding always the Arteries, which are felt by their con­tinual pulsation.

Now the Question is,Objection. How the Ex­crements must be kept back, if the Sphincter be wholly cut away?

For to be convinc'd of it,Answer. you must only represent to your self the dispo­sition of the musculi levatores, which by their union form a kind of ring, that embraces fast the body of the In­testine, performing the same office as the Sphincter. Moreover, I say that the Fibres of the Sphincter being cut, every Fibre coming from each point of the [Page 131]Cicatrice, as those of the Sphincter from the Bladder, and from all the other, may, in contracting themselves, perform still the same office as before, provided much of its substance be not destroy'd by too great suppuration; for seeing these parts are extremely spongy, there might be such a consi­derable passage made, which would cause the Excrements to come out a­gainst our Will; this being explain'd, you fill the Wound with a thick Dos­sel, tied with a thread, dress the rest with Pleagets, sustain'd with a Plaster, Compress and Bandage, of which we have spoken.

CHAP. XXII. Of the Empiema.

What an Empiema is.WE understand by the word EMPIEMA, a collection of matter and blood in the capacity of the Breast. It's taken sometimes for the Operation, and sometimes for the Dis­ease; and tho HIPPOCRATES hath given it a larger extent, when he said that it might be taken for eve­ry heap of Pus in what part soever, notwithstanding it's certain, that it's only proper to this part alone.

Difference of Empi­ema's.The differences of Empiema's are drawn from the place where the mat­ter lieth, and from the different Acci­dents which accompany them. Concern­ing the place of the matter, it lieth between the Plera and the Lungs, or in the substance of the Lungs it self, both these proceed from an internal or ex­ternal cause; from an internal cause, as an Impostumation formed in the Du­plicature of the Pleura, or in the sub­stance of the Lungs, which breaks and runs upon the Diaphragme. From an [Page 133]external cause, as a wound, or from a vessel broke, by some fall, blow, &c.

The Matter doth not al­way fall on the Dia­phragma.You must observe that the Pus and Blood do not always fall upon the Diaphragma, by reason of the adherence which the Lungs contracts with the Pleura, so that they can communicate their inflamation and alteration to one another; and that the matter may pass from the Lungs, through the aper­ture of the wound, without one drop of it being spill'd in the cavity of the breast, which is to be well examined before you separate the Lungs from the Pleura with your finger or Probe, (as most Practitioners are wont to do) that is to say, if the matter run with ease through the Aperture, and with­out the Diaphragma being oppressed with it, you must no ways break the adherence of them.

A Quinsy can never cause an Empiema.I do not speak here of diseases of the Throat; we know well enough that never an Empiema succeeded a Quinsy; the reason is, that the Pus cannot fall upon the substance of the Lungs, without causing a sudden suf­focation, because the Pus, by its weight, would hinder the play of the vessels that compose them; wherefore there [Page 134]is only Plurisies and Impostumes of the Lungs, which precede the Empiema that comes from an internal cause.

Causes of a Plurisy.As for the eause of a Plurisy, some say it's form'd by a boiling and impe­tuous blood, which is extravasated in the Plura; others pretend it's caus'd by a bilous blood, which gathers and putrefies between the ribs and Plura.

Some others maintain that it pro­ceeds from an extravasation of blood that comes from the intercostal veins, and the Aziges; which is discharged between the duplicature of this mem­brane, where it changeth into pus by its stay there: though this last opinion be not over-well grounded, yet it is the most common, and most received.

It were to be wish'd that all these opinions were as true as they are au­thorized by their Partisans; for besides, that the blood being ordinarily spilt out of the vessels only after some blow or wound, it's evident that the bilous particles are rather capable to dissolve a matter than coagulate it, and that it's only the salt volatil alkalies of the Bile which tend to the exaltation; but there must needs be here a coagulating Agent, which disposeth it to be ob­structed [Page 135]in this membrane. There is nothing more common,A common Cause of Plurisies. than to see in the Summer-season Plurisies affect those, who having over-heated them­selves by running, or some other as violent exercise, go imprudently to drink Iced. Liquors, or in a Cellar to cool themselves, having most common­ly their Breast open. You must con­sider, that in the same moment the Pores being much dilated, the blood is in an extraordinary agitation, and fur­nishes abundance of Swetts; this being so, it happens that at the same time as this cold drink chills, (as it were) the blood in the vessels, the impres­sion of the external cold Air suppres­seth the Swetts, in shutting up the pores, and they being quite disingaged from the rest of the mass, stop in the duplicature of this membrane where they coagulate the blood, by the means of their urinous volatil Salt.

Urine and Swett analogous.Experience teaches us, that there is no liquor in the body has more ana­logy with the Urine than Swett; we observe also that it hath the same taste, smell, and consistence; we know that the Urine abounds in a urinous volatil Salt, and in a very aetherious Sulphur.

Now I say that these two spirits, (which are found in the Swett as well as Urine, whose nature and property we have explain'd elsewhere) hapning to be united together in the PLƲRA, in the time of the suppression of abun­dance of Swett, are very capable to condense the blood, and cause the Plurisy, which HIPPOCRATES hath well observed,Sect. 5. Aph. 24. when he says that cold things, as Snow and Ice, are Ene­mies to the Breast, and that they excite Coughs, Dysenteries and Fluxions; Frigida vcluti nix & Glacies pectori Ini­mica, tusses moverit, & sanguines fluxiones, & distillationes movent.

He says likewise, that the Scythians do not live long because they drink Ice waters; and that the frequent use of these waters offend the Breast; for the same reason says HIPPOCRATES, Sect. 3. Aph. 23. Plurisies happen most commonly in the winter-time; as also Peripneumonia's, Coughs, pains of the breast and sides; Hyeme plureides, Peripneumoniae, tusses & pectoris Laterum Dolores.

It's commonly observed, that those who expose their breast to the Air in the beginning of hot weather, are al­most always troubled with a Plurisy; [Page 137]the reason of it is evident, if we make reflection, that no part of the body is so deprived of flesh as the breast, which is the inclosure of the treasure of life, and which consequently is sooner pene­trated by the Air; wherefore those who take care to cover at all times their Breast well, are much less subject to Plurisies, and many other disea­ses.

A Plurisy often from a nitrous Air.The cause of a Plurisy doth not al­ways come from having put your self into a heat, or exposed your self to too great a cold; but it comes often from an Air too much loaded with nitrous and sulphureous Particles, which we attract in inspiration, and which pro­duce the same effect as the principles which we have said are found in the Swett.

Those kind of Plurisies which we call Popular, or Epidemical, happen oftner in Countries where the Earth abounds with Nitre and Sulphur; and where the heat is excessive, as in Meri­dional Regions.

Who most subject to on Plurisy.The constitution of persons contri­bute much to its formation; those who are of a quick wit, whose blood is subtil, and are of a tender Com­plexion, [Page 138]are more subject to it than others.

An Obser­vation on the blood of a pluretic person.It's observable, that after having bled a pleuretic person, there is a little skin form'd on his blood like glue, and almost of the same consist­ence, which has a kind of spring, or elastic vertue; for when ever you handle it with your fingers, it resists a little, and returns into its first posture; it swims upon the blood, even as cer­tain little flanks swim upon the urine of those troubled with the inflamation of the Reins.

As for the Prognostic of this Dis­ease,Prognostics. it is always very dangerous, when Bleeding and general Remedies do not dissipate the Tumor. HIPPOCRATES says, that if one spit from the begin­ning, the disease will be short; but if one spit not till some time after, it will be long: Velut in Pluretide labo­rantibus, si sputum statim appareat inter initia ipsam abbreviat, si vero postea appa­reat producit.

Yet this Rule is not always true, because there are some that do not spit, and yet recover in a very short time; whether that the Humor, which causeth the obstruction, be dissipated [Page 139]by insensible Perspriration, or by the way of Circulation, according to the vertue and operation of the Medicines which are used in this Disease.

The best way of cu­ring a Plu­risy.The most specific Remedies to hin­der the progress of this Disease are Bleeding, which keeps the first rank; and I say, that if it be of any use at all in Surgery, it's without doubt in this occasion,Bleeding no where of so great use as here. because in emptying the vessels, it hinders the Blood from be­ing carried so abundantly to that part, and must consequently lessen the big­ness of the Tumor, in diminishing the quantity of the Blood.

Approved Remedies in a Plu­risy.The other Remedies are those which rarify, subtilize, and attenuate the Blood, as Horse or Mule's dung infu­sed in White-wine, old He-goat's Blood in Powder; all Volatil Salts, and se­veral other Remedies of that nature. The decoction of Nettles in strong Wine, which you sweeten with Sugar, is also excellent; you may at the same time you take the Decoction, lay on the sides the bruised Nettles in form of a Cataplasm.

Of a Pe­ripneu­monia.Having thus in general explain'd the Cause of a Plurisy, I am obliged to say something of a Peripneumonia, [Page 140]that sometimes proceeds from an Im­postume of the Brain, or from the Inflamation of some Membrane which changes into an Abscess, as experience demonstrates in those that die of great Wounds of the Head; but for the most part it's caused by the corruption of the Blood, that is to say, by the ex­altation of its sharpest Particles. All the difficulty is, to know why the Pus, or Blood, stops rather in the Lungs, than in any part else, for to make an Impostumation; I say, that three Cau­ses contribute to its formation, the al­teration of the Blood,Causes of Peripneu­monia. long and slow Respiration, and the structure of the part.

First Cause. Alteration of the Blood.Concerning the first, you must only make reflection on the nature and mix­ture of the Chile, and thickest Blood, which the right Ventricle of the Heart sends in every Sistole to the Lungs, through the Pulmonic Artery. We know that these two Liquors pass through the Heart and Lungs, for to receive some necessary preparations for the function of the parts; therefore we may say that they are the two recep­tacles of all that is most thick and in­digested in the mass of Blood; but if [Page 141]the Heart hath the strength and power, by its constriction, to subtilize, and cast off all that is most heavy and material in the mass, the Lungs have not the same advantage, as we will prove; so that the grosser substances being ac­companied with some impurity, and having only felt the first effects of the Heart for its perfection, it must needs stop there, and putrefy.

Second Cause. Long and slow I espi­ration.The second Cause which I establish, is a long and slow Respiration. It's certain, the more free the Air enters into the Breast, and the more the Ves­sels are extended, they are in a more fit condition by their elastic vertue or spring, to express the Air through the Pipes of the Trachea Arteria; and the more the Blood is agitated by the in­spiration of the Air, it's driven with greater quickness into the Veins: But on the contrary, if the Blood is mo­ved slowly by a long Respiration, it follows that the Vessicles being not so extended as they should be, and not expelling the Blood out of them with such a violence, it stops and corrupts there gradually, by the arrival and mixture of some ill Leaven, or by the exaltation of its salt Particles; from [Page 142]whence it comes, that those who have a long Neck, are more subject to it than others, because the Air is obliged to make a long traverse before it comes to the Lungs, which makes them dry up, and alter insensibly.

Third Cause on the Stru­cture of the Part. What the Lungs re­ally are.The third Cause is grounded upon the Structure of the Part; the Lungs are a complication of little Vessicles, in which the Arteries pour the Blood, and where it's mingled with the Air, to receive some alteration there. Now it's shew'd in the Hy­dravlic's, that a Liquor which passeth from a little Pipe into a greater, loseth much of its motion; and being the Arteries are very little, in proportion to the Cells, it's no wonder if the Blood grow slow there, and changeth its nature by the exaltation of some sharp and tartarous Salt, and by the Fermentation which they cause there; wherefore the alteration of the Blood, the irregularity of Respiration, and the largeness of the Vessicles of the Lungs, in proportion to those of the Arteries, are the three Causes that concur to the formation of the Perip­neumonia.

Since the Signs of all these kinds of Diseases are of the greatest impor­tance to succeed well in the Operation, and to make a favourable or dangerous Prognostic, I will endeavour to de­scribe them with all the Order that is possible.

Signs of Pus, or Blood in the Pleura.The Signs which shew us that there is some Pus, or Blood stopt in the Pleura, are Inflamation, penetrating Pain, Heaviness, a languishing and con­tinual Fever; a hard, thick, and deep Pulse, accompanied with shivering; difficulty of breathing, a dry Cough and Thirst; one cannot lie on the sound side, by reason the matter lieth heavy on the Pleura; and one grows lean and thin in a few days.

Signs of the Matter on the Dia­phragma.But if the Impostume break, and the matter falls on the Diaphragma, all these Symptoms cease, and the Patient finds some ease for a time; but immediately there comes others not less dangerous and insupportable; besides, the diffi­culty of breathing, which is common to every Empiema, one feels a heavi­ness upon the Diaphragma, fluctuation, a great uneasiness; the Fever increases, and becomes burning; the Pulse rises, the Pain indeed is not so sharp, it be­ing [Page 144]felt towards the false Ribs, one cannot lie but on the side where the matter is; for if you lie on the oppo­site side, one feeleth a twitching upon the Mediastinum, more cruel Pain, and a much greater heaviness; their spittle is sometimes stinking, and there fol­lows very often Impostumes of the Liver, after these kind of indispo­sitions, even as it is observed after great wounds of the Head.

If the Pus be diffused on both sides, one cannot lie on either, by reason of the sharp Pains one suffers; to be ea­sed, you must lie upon the back or belly.

Signs of Pus in the substance of the Lungs.The Signs when there is Pus in the substance of the Lungs, may be divi­ded into equivocal and convincing; the equivocal belong to other Diseases of the Lungs; it's very dangerous to be mistaking, therefore let's endeavour to examine them well, that we may draw some advantages, and that we may not undertake an Operation whose effect would prove not only useless, but fatal.

If there be any Pus in the substance of the Lungs, the diseased cannot breathe without pain; he finds an in­supportable [Page 145]and troublesom heaviness upon the Diaphragma, because the weight of the matter deprives it of the liberty of moving. He suffers a fixed and dull pain, which is a com­mon sign of a PLURISY, with this difference, that the Pluretic Pain is pungent, comes all of a sudden, whereas the Pneumonic Pain, (that is to say, that which proceeds from an Impostume of the Lungs) comes only by little and little, and successively. The continued Fever doth not leave, accompanied sometimes with an im­moderate thirst; his spittle is purulent, his mouth and throat dry; he hath red cherry cheeks, sunk and hollow eyes, having lost their lively and glit­tering colour; his nails bend back­ward, and the whole body grows at lest dry and emaciated; and if the Fever increase, the Patient falls into Delirium, and his Spittle be black, livid, or ash-colour'd, Death is not far off, because they are mortal Symptoms, which oftentimes accompany it: So much for the Impostumation of the Lungs, which comes from an internal Cause.

Let's now examine those that follow the Impostume of the Lungs caused by Wounds; the difficulty of Breathing is not so considerable; the Fever is continual, accompanied with shivering, and cold Sweats, which appear from time to time; these two last accidents are depending from the Pleura. The Patient spits pretty often Blood in the beginning, and towards the end it's frothy and purulent. When the Spittle is of a yellow colour, it's mortal; he cannot lie but on his back, because being on his sound side, the wounded Loab li­eth heavy upon the Mediastinum, and causeth a twitching and cruel pain; and when he turns himself on the wounded side, the Lungs coming to lie heavy upon the Pleura which is hurt, doth not fail to excite the same pain, where­fore he dares not stir.Signs of the Lungs being wounded. In the begin­ning his eyes are brisk, but at last they grow dull, and the face puffs up; but the most certain Signs that the Wounds reach to the capacity of the breast, and of the Lungs being hurt are the Probe, the noise which the Air makes in coming forth, and the Em­physema.

When you probe, you must observe to make the Patient put himself in the same posture he was in when wounded, that the extravasated blood may run easier out.

If the Wound penetrate to the sub­stance of the Lungs, the Blood which flows is forthy, and the Air makes less noise, and comes not out with such impetuosity, as when the Wound pene­trates only the Breast, without touch­ing the Lungs.

If one asks,Objection. Whence cometh the Air that is in the capacity of the Breast, the Lungs not being alter'd, and the reason why it makes such a noise?

You may answer,Answer. That it's the out­ward Air which is got in through the mouth of the Wound, and endeavour­ing to escape, because of the expan­sion of the Lungs, which press it every where. It hapneth that those Particles which appear at the passage, not being able to get out but with a great deal of pain, through the resistance of the external Air, and the smalness of the Aperture, push and press one another so hard, that they must needs make a noise, and produce a kind of [Page 148]whistling, (passing out of the breast) which can put out a Candle held to the mouth of the Wound.

Cause of the Em­phisema.The Emphisema is likewise only cau­sed by the particles of the Air, which penetrate the Porosities of the neigh­bouring parts, which swells and blows them up; so that often one cannot find the mouth of the Wound, nor introduce a Probe.

It's easy to see from what we have said, that the Emphisema and the Air's coming out of the breast, are not al­ways convincing signs of the Lungs being hurt, because they happen when the Wound penetrates into the breast, without having touched the lungs; wherefore there are only the signs (which we have spoken of) that can give us afterwards certain marks of it; but the Probe, and the exit of the Air, are two true signs that the Wound penetrateth into the breast.

You must observe,Caution. that if the breast be pierced through and through, you must never let both the orifices be open at once, for fear you choke the Pa­tient; the reason of it is evident, be­cause the Air cannot enter by two [Page 149]opposite sides without compressing the Lungs, and hinder the motion of the Breast.

I have said, that the true scituation, when the Lungs are alter'd, is to lay one down on the back for to ease the Patient, because the Bronchia are compressed by the weight of the extravasated blood, which presently takes away the liberty of breath­ing.

I intend to speak here of the super­ficial Wounds of the Lungs; for if they be deep, and that any great Ves­sel be divided, one feels almost as much pain lying on the back, as on the sides.

A certain Sign of ex­travasated Blood in the body of the Lungs.But one of the most certain Signs that there is some Blood extravasated into the body of the Lungs, and of which we have not yet spoken, is, that if we put our Finger far enough into the Wound, (provided the bigness or Diameter of the breast permit it) we find that the Lungs are fastned to the Pleura round about the Wound, and reunite themselves there, even as the Intestine is united to the Perito­neum.

A Sign that the Wound has not passed the Pleura.The Signs which demonstrate that the Wound doth not pass the Pleura, are the Probe, and the Air, which never passeth through the Wound: There are some others, as the Pain, Inflamation, Fever, Heaviness, and Dif­ficulty of Breathing; besides the thick­ness of the exterior parts, which may in some manner guide us for to be sure of it.

All these Signs nevertheless do not always shew that the Wounds are deep, since a simple Inflamation of the Intercostical Muscles hinder free Respi­ration. If we consider that the use of these Muscles is to raise the Ribs, to enlarge and widen the Cavity of the Breast, and that Inflamation and Ten­tion are utterly contrary to their Action; we shall agree, that the Lungs cannot dilate themselves but with dif­ficulty; and seeing the Contraction of an inflamed Muscle encreaseth the Ten­tion, and great Tention many Divul­sions, and many Divulsions vehement Pain, you must not wonder if the Dis­eased (for to ease himself a little from the Pain) retard the course of the spi­rits, and have very great difficulty of Breathing.

Cause of the Heavi­ness.The Heaviness proceeds from the Impotency of the Muscles; for as soon as a part is out of action, it seems heavy to us, for it's a burthen which the neighbouring parts must support; and being they have neither strength nor motion to raise what offends, they must succumb under the weight of a new and superfluous matter, from whence depends the Heaviness.

We have explain'd in several places of this Treatise the cause of Pain, In­flamation, and Fever; we have said that the Pain is excited by some actual Divulsions, by whose occasion the Soul perceiving the destruction of a part, is afflicted, the Inflamation hapneth when the course of blood is hindred in any part, and that it's sufficient to produce the Fever, (which is a Consequence of the Pain and Inflamation) if a drop of extravasated and corrupted blood be carried to the heart.

Cause of Red Cheeks.One hath Red Cheeks in an Im­postume of the Lungs; this comes from the irregular motion which the puru­lent Particles communicate to the Prin­ciples of the Blood, and from the great number of Blood Vessels which irri­gate the Cheeks.

Cause of the Dulness of the Eyes.The Eyes lose their vivacity, and sink into the head, because the blood loseth its consistence and colour; in losing its oil and unctuosity, which makes the Eyes sink, and become in­sensibly wan and dull, proportionable as the sharp and tartarous Salts dissi­pate the oily and sulphureous Par­ticles.In all Dis­eases of the Lungs, the Caule and Mesente­rium al­ways cor­rupted. This, I say, is so true, that in all Diseases of the Lungs, we always find the Epiploon and Mesenterium (which are the two Reservatoriums of the Fat) corrupted; it's for the same reason that all parts of the body dry up and grow lean.

What gives the Red Colour to the Blood.You must also observe, that the Red Colour of the Blood doth not only depend on the mixture of the Sul­phurs, but also on the action of the Air which whirl about its Particles; and being the Air that gets into the impostumated Lungs changes its na­ture, it's no more capable of setting them in motion, neither to excite so lively a Sensation as before.

Cause of the Nails bending back.The Nails bend backward, because their Extremity being irrigated with a serous Liquor deprived of Spirits, the Cutis must of necessity fall away and dry up; now as the Nails are [Page 153]only a production of it, it pulls them along, and constrains them to bend like as a slice of Bread held to the Fire.

You must look upon all these signs as certain tokens that the Wound pe­netrates into the breast; you may stay some days to examine its progress; for if they proceed from a not pene­trating Wound, in a few days they cease by bleeding and suppuration; and they continue and increase when the Lungs are alter'd, or when the Dia­phragma is oppressed by the weight of some extravasated matter.

An Em­phisema may happen to any parts of the Body.The Emphisema is not always a sign that the Wound penetrates, because it may happen not only to Wounds of the breast, but also to all other parts: We see it even to come on Wounds of the Head, where we cannot suppose the Lungs to send any Air; so that unless the oppression be very great, you must not try the Operation.

These signs do not only lead us to the knowledge of the nature of the Empiema, but they tell us also whether it's necessary to practise the Operation: [Page 154]For example;Where the Operation would be useless. it would be useless in the Empiema of the Lungs, by reason the opening of the breast contributes nothing at all to the evacuation of the matter, unless the Impostume be on the superficies of the Lungs, then it would be of more use, because we know that the Lungs are fastned to the Pleura, and the Impostume is pre­cisely where one feels a fixed pain; but if so be the Impostume should be deep, and manifest it self in that place by a fixed pain, it would be fruitless. If the effusion of the blood should happen from a Wound, and that by good luck the Wound were in a place where the extravasated blood could easily get out, (provided the Lungs were not adherent) by enlarging the mouth of the Wound to make way for it, or by laying the Patient in a posture convenient for the running out of the matter, the Operation would be useless. Finally, let the Wound be of what manner soever, if we can fa­cilitate the evacuation of the Pus, by making the Aperture bigger, we ought to avoid the Operation; but if the Matter cannot have its free course, you [Page 155]must make use of it, for to deliver the Patient from suffocation, and the chiefest circumstance of the Operation is, to chuse a proper place to facilitate the exit of the matter.

The most proper pla­ces to per­form the Operation. Of Necessi­ty.There are two places in the breast proper to make the Operation, one of Necessity, the other of Election; of Necessity, where the matter appears, as in the Impostumation of the Pleura, or in that of the superficies of the Lungs adhering to the Pleura, because we are forc'd to make the Operation where the Impostume is: that of Election,Of E­lection. when there is nothing that obliges us to make it rather in one place than another, in this case you must chuse the most convenient place, which is be­tween the second and third of the true Ribs, reckoning from below upwards four fingers from the inferior Angle of the scapula, and as much from the spine.

You must observe, that in those who have been troubled with any long Dis­ease of the Breast, as with a long Pleu­risy, &c. the Diaphragme is insensibly fastned to the Ribs, and reaches some­times even to the third, fourth, or [Page 156]fifth Rib,A Caution to be ob­served. particularly when the breath­ing is frequent and forc'd; therefore you must inform your self which is the place where the diseased feels the pain; if it be about the second of the true Ribs, where ordinarily the Diaphragma is fastned; or if it be higher; which must be well examined before you make the Operation.

CHAP. XXIII. Of the Operation of the Empiema.

HAving preparel all that must pre­cede such a necessary OPE­RATION, you place the diseased on a Chair or Bed; he must keep his Body very strait, and be held up by Servants, that the Chirurgion may the easier take notice of the place where he's to make the Incision. In fat People you make it somewhat large, that you may not be mistaken.

How to per­form the Operation.You pinch up the Teguments for to cut them at length, (with a Bistory) and the fibres of the great Musculus Dorsalis cross; for if they were cut otherwise, they would stop the Aper­ture of the Pleura, and so hinder the running out of the Matter; you con­tinue to incise dextrously the Inter­costal Muscles: some incise them at the uppermost part of the Rib, to avoid the Vessels that lie all along its internal lower Sinus; but seeing the Wounds, which are near the Bones, degeneration often into Fistula's,Caution. it's [Page 158]more proper to make it in the middle of the Intercostal Muscles.

When you are come to the Pleura, you put your finger there, all along which you slip a Bistory for to Incise the Pleura, minding to guide well the point of the Instrument with the fin­ger, and penetrate not too deep, lest you offend the Lungs or Diaphragma, which are often fastned to the Pleura; the Aperture being made, you put your finger into the Cavity of the Breast, as well to make the Incision bigger, as to push back the Lungs and Diaphragma, and to loose them, if they are fastned to the Pleura, particu­larly where the Operation is made in a place of election, different to that which is practised in a place of neces­sity, without breaking the Adherences, as we have observed in the foregoing Chapter.

If the Lungs strive to come out at the orifice of the Wound, you must push them back with a blunt hollow Probe, (for to help the running out of the Matter) or with a Pipe of a thickness and length proportionable to the deepness of the Wound. These long Pipes are very useful in the Em­phisema, [Page 159]because the Aperture of the Wound being little and deep, it's very difficult, without their help, to give Issue to the Matter.

You must not make use of a Probe,Caution. to try whether the Pleura be pierced; for in passing, it often separates from the Ribs, and there is a Vacuum made where some Blood is apt to gather, which produces a new Impostume.

More Blood to be drawn at a time than Mat­ter.If it be Blood that comes out of the Aperture, you may draw a sufficient quantity of it; but if it be Pus, less, by reason it contains more spirits, and the Patient is apt to fall into a Syncope. After this, you stop the Wound with a blunt Tent of Lint, having a large head, and being a little crooked at the end, lest it offend the Lungs. Most commonly we tie a Thread to it, fill the rest of the Wound with little Dos­sels of dry Lint, to keep the Tent in, and absorb the Blood, and lay a Plaister on it, with Compress and Nap­kin about the Body, with the Scapu­lar, which is cut in two at one end, and put cross, to fasten the Nap­kin the easier. When the Patient is dressed, you make him keep his Bed with his Head high, as if it [Page 160]were half sitting; and you let him rest, till he finds himself oppressed with the weight of a new Matter; then take the Dressings off, and having made the Matter run out, you push the Lungs back with a long Pipe, by whose means you facilitate the flow­ing of the Matter that remains in the Breast; you continue to dress it so eve­ry day.

We observe often, that the first three or four days Blood comes out, the next days Water, and afterwards Pus, that groweth thick by little and little.

We have observed already, that in case the Empiema should afford much Matter, or Water mixed with Pus, you must not evacuate it all at once, lest the Patient should fall in some weak­ness.

The Air to be corrected when you dress the Patients,You must always correct the Intem­peries of the Air with fire when you dress the Patient, and hinder it from entring too abundantly into the Breast, because it thickens and coagulates the matter which is extravasated there, hin­ders it from flowing, and causes it to come forth in Clods. If it be Blood, the Serocity separates from it, as after [Page 161]letting Blood; nevertheless, whether the Pus or Blood be thick, or mixt with some Water, you always use (with Prudence) Injections of Barley Water, and Mel Rosar. with which you cleanse the Lungs and Breast; you must always cause the injected Liquor to come out by the help of the finger, or hollow Probe; and if the Lungs should stick, you must loose them.

If in time the Blood should grow too watry, and the Patient be oppres­sed by the quantity of the Pus, you would do well to dress him three or four times a day.

The Matter runs sometimes for the space of three or four months, and as soon as there comes nothing out but what comes from the Wound, you pro­cure the generation of flesh, and cica­trize.

You must observe, that when the Air works upon the Blood that is in the Breast, it coagulates it sometimes, without changing it into Pus, and so it comes out in Lumps.

Bitter things not to be used in Injecti­ons.You must not use Injections in the beginning, neither make them with Aloes, or other bitter things, because when the Lungs are open, the Patient [Page 162]casts them out through the mouth; but after the Vessels are consolidated, you may use the tincture of Aloes, or Wine mixt with a traumatic Deco­ction, and Mel Rosarum; this is used when the Pus comes out in a small quantity.

Often after a wound of a Sword, there comes out of it an abundance of blood, and after three or four days no more appears; in this occasion you must quickly close the Wound, and you have all the reason to believe, that there were only some little Vessels broke, which gave some blood, and which afterwards were stopt by the most glutinous particles of the blood; of the rest (however the thing hap­pens) there remains no danger.

CHAP. XXIV. Of the CANCER.

I Look upon a CANCER as the most inflamed and rebellious of all the schirrous Tumours; the red part of the Blood as well as the white contribu­ting to its formation.

Principal Causes.When CANCERS happen in glandulous parts, there is great ap­pearance that the Lympha is the prin­cipal cause there; if they attack any other part, it's to be presumed that the Tartarous Particles of the Blood have the greatest share therein. However it be, I say that the concourse of these two Humours is always necessary for the production of a Cancer; all the difficulty is, well to distinguish which of those two predominate.What a Cancer is. I say a Cancer is a round, hard, unequal, livid, and painful Tumour, caused by the meeting of abundance of Acids, and of the Tartarous Particles of the Blood, from which proceeds the pain and tention of the Vessels, which very well represent the Claws of a Crab.

Cancers of the Glandulous Parts most painful.Those CANCERS which pos­sess the Glandulous Parts, are much more painful than the others, through the abundance of Nerves which enter into their Composition; and if the alteration of the Lympha contribute any thing to their generation, it's be­cause the Glands are its principal Re­servatories.

Cause of the Round­ness.The Roundness of the Tumour, cometh from the Round Figure of the Glands, because the Humours which cause the Obstruction, and extend the Vessels, can easily tumify these Glan­dulous Bodies, without changing their Conformation.

Cause of the Ten­tions, &c.As for the Tention, and fulness of the Vessels, it's known that the Mat­ter which they contain, is nothing else than the Matter which forms the Tu­mour. This Humour is Tartarous, fixt, and gross, and consequently not very capable of Fermentation; the slow progress the Tumour makes in the beginning, is a convincing Proof of it.

The Lympha being acid, it may well excite some little Fermentation with a porous and terrestrial Salt, which the red part of the Blood furnishes; but it [Page 165]serves rather to fix and concenter the Humours yet more than they were be­fore.

If this Fermentation were capable of causing the fulness and tention of these little Vessels, it would be doubt­less too slow and weak to break them so soon; the Matter lieth long there quiet, till having been exalted by the Application of some Medicines,How the Cancer ulcerates. it gnaws the Vessels and Vesicles which contain it, then, I say, the Cancer ulce­rates.

The Vessels which are puft up in a Cancer, are so little and tender, that one cannot distinguish them in their natural state, nor take them for what they are, if one did not see them fill'd and extended; the Humour that is within these Channels and Vessicles, not being presently able to ferment enough to break them, as I have al­ready proved, it's at least sufficient to extend and make them appear.

You must not think that the extre­mities of the Vessels are open for the most attenuated and subtilest Particles of the Matter to escape; I do not be­lieve that in the Cancer there's found [Page 166]any Matter in the Interstices of the Ves­sels, till the Vessicles beginning to break, that the most active and exalted part of this Humour may run out: I say, that as soon as some Particles are dif­fused, being they are very corrosive, it's then that the Exulceration of the Cancer hapneth; and as it is sometimes long without Ulceration, I maintain, that during all that time of the Tu­mour, the Humours are always pent up in the Vessels, different to other Tumours, whose course of Humours are very rapid, and their Fermenta­tion very quick and violent, which causeth the Vessels to break, before one hath perceived the swelling of them.

We observe that the Vessels of the Eyes, which in their natural state are imperceptible, grow manifest enough in Opthalmia. From what I have said, you may easily draw the Differences and Prognostics of Cancers; Differences of Can­cers. there are external, and internal; great, little; ulcerated, and not ulcerated, as in all other Tumours. As for their pro­duction, they must always have an acid Juice from the Lymphatic Ves­sels, [Page 167]whose Obstruction causeth the Retention of the Lympha, and makes acid an adust and terrestrial Matter from the Arteries and Veins.

The Cancers that happen to the Paps,Prognostics. and other glandulous parts, are the most dangerous, because it's always more difficult to remedy the disorders of the Lympha, than those of the Blood. Besides, these parts are very sensible, and more susceptible of ill impressions than others, which you may more successfully secure from the Symptoms which the Cancers may cause.

The Cure of Cancers (which one may well call Opprobrium Medicinae) is very difficult.Cure. If some Quacks boast of having some infallible Remedies for them, Experience soon makes us see their Imposture. Cancers are very selfdom cured by the use of Medicines, Chyrurgery sometimes succeeds better, but is always very dangerous: Qui­bus sunt occulti Canceri (saith HIP­POCRATES) eos prestat non cura­re, curati namque: Citius intereunt, Sect. 6. Ap. 38. quam non curati; therefore it's a great piece of Imprudence to undertake the Cure [Page 168]of an Internal Cancer, unless it be small, and the extirpation of it very easy.

Cancers exaspera­ted, rather than cured by mild Medicines.Concerning the external ones, they are always difficult to conquer; the reason is, that unless we use a very great circumspection in chusing Reme­dies that are proper, we do not fail to irritate them; whereas the other Hu­mours are appeased by the action of Remedies, and grow at least suppor­table, this seems not to receive any impression, but rather to become more furious, and to make more destru­ction.

The general method of curing a Cancer.The general Remedies are abso­lutely necessary for the Cure of a Cancer, as a Sobre Regiment of Life, frequent and gentle Purges, Phleboto­my; the Flux of the Hemorrhoids in both Sexes, and the regular Flux of Women, give the Patient great ease.

All sorts of Cancers to be hand­led alike.Let the Cancer be in what part so­ever, it's not treated with much di­versity, unless it be ulcerated; and though it seemeth that we are more timorous to apply Remedies to those which possess the glandulous parts, [Page 169]than to others; yet when we un­dertake their Cure, we make use indifferently of the same Remedies, as we for the one as the o­ther.

What sort of Medi­cines not to be used.Those that use sharp and corrosive Remedies, or else too active and pene­trating ones, never fail to make the Disease incurable; the softer Reper­cussives and Supuratives one can [...]ap­pily employ in other Humours, are here the most dangerous. The rea­son of it is most evident, to any that knows the Principles of Chymistry: The Matter of the Cancer is course,The Matter which cau­ses a Can­cer, fer­ments not so soon as in other Tumours. fixt, and tartarous, therefore it cannot easily ferment. If you let it alone, it requireth a considerable time for the exaltation of any of its sulphureous Salts which it contains; but if you stir it by some fermentative and pene­trating Remedies, from being fixt and immoveable as it was, it becomes very active and penetrating, because the Salt and Sulphur (which it con­tains) exalt themselves, and take the upper hand; then doth this dead Mass, which seem'd before uncapable of ma­king any disorder, change into a Vi­treolic [Page 170]and Arsenical Matter, which gnaweth and wastes the parts which contain it, and are nigh, till at last it arrives to the most internal parts, and causeth Death soon or late, according to the diverse nature of this Matter, and the progress it makes in the parts.

I say then, that the Cure of a Cancer (that is not ulcerated) must be at­temp [...]ed with the softest Remedies; that which cools, tempers, dissolves, repels the Humours by little and little, without exciting them to ferment;Remedies most pro­per. that which is capable to stop the flow­ing Humours, as Ap. Solani Plantag. Fragrariae, Spermat. Ranar. Lumbricor. Sal. Saturni Cream, New Cheese, Flesh of Veal, which we change when it's corrupted. Finally, all that mollifies and softens this Rebellious Tumour, and repels it in softning it; all this, I say, may cure Cancers, or at least not irritate them: And though the Reflux of the Humours could seem dangerous, yet it's the ordinary practice to go about it after this manner.

What to be used in an ulcerated Cancer.When the Cancer is once ulcerated, the Remedies which we must use, are those which can hinder its progress, [Page 171]and ravage; nothing stops it more surely, than Alkalisaporous Salts, mixt with some Astringents: these fortify the part with their styptic ver­tue, and the other blunt, and absorb the points of the Vitreolic and Corro­sive Salts, that causes all that disorder. All Authors recommend this practice, and if it hath not altogether an ad­vantageous success, you must have re­course to the Extirpation of it, seeing neither Resolution nor Supuration is to be hoped for.

CHAP. XXV. Of the Extirpation of the CANCER.

Three ways of extirpa­ting a Cancer.THE Cure of a Cancer may be at­tempted by Incision, by Ligature, or by Actual Cautery. If you under­take it by Incision,(1) By Incision. you must cut its most deepest Roots; that is to say, you must anticipate upon the nighbouring parts, and having taken it off, you must squeeze the adjacent Vessels to make the Blood and Humours come out, which may have contracted ma­lignancy.

In respect of the Ligature,(2) By Liga­ture. it's not much in use; but if you would put it in practice, it must be when the Bases of the Tumour is but small, when the Roots extend themselves not far in compass, and when it terminates in a kind of strangulation; but being it is rare (not to say impossible) to meet with such a disposition, the Ligature has no other use than that of suspend­ing the Tumour, that you may make the Incision more commodious.

You must observe, that if you apply slightly the Actual Cautery after the Operation, it's to stop the blood,(3) Actual Cautery. and absorb and destroy some portion of the unclean matter, which could serve as a Ferment for the Generation of a new Cancer, and might even infect the whole mass of blood.

How to per­form the Operation.The method used in performing the Operation is this; you introduce into the top of the Tumour a Needle arm'd with double Thread to make a sort of Loop, with which you uphold the Tumour, and the Surgeon cuts it round about the Base 'till to the Ribs, with a very sharp Knife; having taken off the Tumour, you squeeze the blood out, and pass slightly over it an Actual Cautery, you dress the Wound with Pledgets arm'd with astringent Powders and lay a Plaister on it with Compress; Napkin and Sca­puler.

The best way of ox­tirpating a Cancer.But the best method is to make an Incision cross over the Tumour, even to the Ribs, and separate dextrously the flesh from the skin; by this means you avoid the great deformity and pain, and secure better the Wound from the Air.

If the Diseased be not in a disposi­tion proper to endure to Operation, either through fear of pain, or being weak, and the Surgeon not make a favourable Prognostic, it would be a rashness to undertake it; besides, that the great loss of substance, and dange­rous accidents which happen, are wor­thy of reflection, which break often the measures that the most daring Pra­ctitioners can take: for as soon as the Tumour is taken off, the Ulcer grows often malign, painful, and of a round figure, which is a mark of slow cica­trisation; the sides become calous, li­vid, high, black, and inverted, accord­ing to the disposition of the Juices with which they are water'd.

An extra­ordinary way to cure a Cancer.There are some (that without per­forming the Operation) do assure us, that they have cured ulcerated Cancers with great Red Snails freed from their shells, which are laid upon the Ulcer; they say that they creep sometimes about the Ulcer, fasten to it, and leave their foam there; that we find the bottom of their belly gnaw'd as it were, and they grow so monstrous, that in a short time they burst.

The reason is, that these Animals contain an abundance of Volatil Al­kalys, which charge themselves with the Acids that entertain the Cancer, and which grow and ulcerate the belly of these Animals; so that being con­vey'd through the little branches of their veins, into their mass of blood, according to the order of Circulation, they excite such an extraordinary Fer­mentation, that these Animals must needs perish.

CHAP. XXVI. Of Bronchotomia.

Broncho­tomia, a nice Opera­tion.THere is no Operation in Chyrur­gery of a more nice undertaking than the Bronchotomia; neither is there any more pressing or useful, when ever one has the happiness to succeed in it.

The Causes of this troublesom Af­fect,Causes. proceeds ordinarily from some Wound, great Crying, long Discour­ses, violent Passions, or the alteration of the Humours.

If a simple Inflamation be capable of hindring Respiration, what will not happen if any of these Causes concur to increase it? Now whether the In­flamation attack the Muscles of the Larynx, or some other parts, it com­municates it self not only to the Aspe­ra Arteria, but also to the Muscles of the Pharinx, and neighbouring Glands, which obliges the blood and spirits to stop in all these parts, and to cause [Page 177]great obstructions, then doth the blood (which without intermission pressing on) not finding its passage free, stay there, and augment both Inflamation and Tention; the Vessels being after this manner distended, and swoll'n up, take up more space than before, and must needs press the Aspera Arte­ria, and hinder the passage of the Air in that part, whence follows Suffoca­tion.

Bleeding, Clysters, Resolutive Ca­taplasms, Gargariems made with strong Wine, in which you boil (in B. Mariae) Sanicle, Golden Rod, Perivincle, and Angelico, with many other Remedies, are to precede the Operation, unless danger of Suffoca­tion oblige us to make it.

If the Obstruction and Inflamation attack only the Amigdals, or Glandulae Tyroides, you must endeavour to open them by the mouth with the point of a Lancet arm'd with a band of Lint. If all parts of the Throat be inflamed, and all Remedies proved without suc­cess, you must betake your self to the Operation.

How to perform the Operation.To do it methodically, the Patient must sit upon a Bed or Chair, with his head back, leaning on a Ser­vant's breast, who upholds it with his hands.

Being in this posture, the Surgeon chuses the most convenient and less dangerous place, where he may make the Operation, which is a Thumb's breadth from the Larynx, between the third and fourth Ring of the Aspera Arteria, he pinches the Cutis, &c. cross: makes an Incision at length, and separates very gently and arti­ficially the Brochales, and Musculii Sternobyoidei.

Having discover'd the Aspera Arteria, Caution. you incise cross-ways (with a Lan­cet arm'd) the Carnous Membranes which ties the cartilaginous Rings to­gether, avoiding the recurrent Nerves, which carry the spirits necessary for the function of the organ of the voice, which (if they should chance to be cut) would be lost.

The Incision being made, before you withdraw the Lancet, introduce a Probe, which facilitates the entry of a short Pipe, which must be crooked, [Page 179]and proportionable to the Wound; there must be a hole on each side to pass a little Ribon through, which is to be ried behind the Neck to keep it fast; we put a little Cotton, or piece of Sponge at its entry, for to modify the Air a little, then apply a Plaister on it with holes in it, Compress, and a pierced Bandage.

CHAP. XXVII. Of Fistula Lachrimalis.

THe Fistula Lachrimalis is always caused by a sharp and salt Hu­mor. If the Matter of the Tears, which run through the lachrimal passages, have received any alteration, it may cause some obstructions in those pas­sages, which terminate at the Aperture of the os lachrimale, without communi­cating its alteration to the neighbour­ing parts. I will not call this indispo­sition a Fistula, When the Operation is not neces­sary. but Obstruction, which nevertheless permits the serosity to es­cape involuntary; which must be well distinguished, because the operation is not necessary if the lachrimal Bone be no way alter'd; for the Operation consists in nothing else but to pierce the Bone, and consume the Cariosity. We use in this occasion general Reme­dies, and all Coliriums proper to de­obstruct and disinflame these parts.

If the Matter which causes the ob­struction excoriate, and slightly ulce­rate the nigh parts, one may call it [Page 181]a false Fistula, which yields to attenua­ting Medicines, and those which are proper to consume the Calosity that comes upon it.

But if the serosity by its acidity ex­coriate the little Tubercle of Flesh, which the Ancients took for the lachri­mal Gland, and the other nigh parts; there comes upon it an Ulcer, which soon degenerates into a Fistula, by the action of the most pungent and acid Particles; as I have proved at length in the examination of the Fistula in Anc. So that this impure serosity, be­ing capable of Corruption, rots the Bone by its lying there,What a true Fistu­la Lachri­malis is. and stop the passage of the Tears. I will call this the true Fistula, where the operation is of great importance.

It happeneth often that the same Humor which waters the Eye, runs to the lachrimal Sac without producing its effect: The reason is, because it beginneth only to enter into its first degree of Corruption. But this Sac being a production of the interior Membrain of the Nose, which is ex­treamly spongy and penitrable; the Humor has strength enough to peni­trate it, and so cause an inflamation [Page 182]which stops the passage of the Tears, which by lying there wax sour, and afterwards grow so sharp, that they cause a Fistulous Ulcer, or a kind of Fistula which one might call complete, to distinguish it from the others.

The Matter of the Tears is not al­ways the cause of this Fistula, as it is the effect of it: It's very often the consequence of some Imposthume, or even of the inflamation of the lachri­mal Sac, without this pretended sero­sity contributing any way towards it: It may truly by lying still there, thicken and harden by heat, or it may dege­nerate, mixing with some other strange Humor, and so contribute to its Formation.

You must observe, That in this last kind of Fistula, there is always some Pus in the lachrimal Sac; the most of them that are troubled with it, press every day the fide of their Nostrils, to squeeze out the Matter, so they may avoid the pain of the operation, be­ing rather content to have it as long as they live.

CHAP. XXVIII. Of the Operation of the Fistula Lachrimalis.

How to perform the Opera­tion.WE have already said, that the o­peration of the Fistula Lachri­malis consists in piercing the Bone, and making the Matter which entertains it flow more easy, and in deobstructing the passages.

For this you introduce the Probe to know whether the Bone be discovered or carnous; but particularly whether its hole be stopt.

If the exterior Orifice of the Fistula permit not the entry of the Probe,Caution. you must dilate it with a little prepared Sponge, or make an incision with the Bistory, taking care not to cut the little Bridle, which makes the reunion of the two Eye-lids; which is no­thing else but the Tendon of the Or­biculer Muscle, that performs the of­fice of a Ligament: for if by chance it should be cut, the lower Eye-lid would be revers'd, which is an indis­position [Page 184]much more troublesome and deform'd than the first.

When you have made the Incision, you fill the wound with dry Lint to obsorb the Blood, and dilate the lips to see more easily the bottom of it. The Bone being laid bare, you intro­duce a little Canula into the hole of the Os Lachrimale, and with actual Cauteries of different Figures you pierce the Bone, which is very thin; lightly passing the Cauteries over its surface to hasten Exfoliation, and de­stroy the Cariosity, if any. After that you procure the suppuration of the would, and lay in the bottom of the Fistula Medicines proper to procure Exfoliation of the Bone.

What to be done to pre­vent Infla­mation.You must observe, That before you make the Operation, it's necessary to apply on the Eyes some defensative made with A (que) Plantag. Rosar. Album. ovi, Ol. Rosar. & tutiae, you continue to use it until there is no more fear of Inflamation.

When the Operation is finished, you order the Patient to lie on his Back, that the Matter of the Tears may take its course through the Aperture that [Page 185]hath been made; you must have re­gard to two Circumstances. The first, to stay till the rottenness be destroy'd before you procure the generation of Flesh. The second, to hinder the ci­catrize from rising too high, which would be a very disagreeable deformi­ty. Finally, you apply a Plaister, Com­press, and a Handkerchief a-cross, or the lachrimal Band.

CHAP. XXIX. Of the Polypus.

FOR to have a Idea of the gene­ration of the Polypus, you are only to call to mind what we have advanced, when we spoke of a Sar­coma; and to make, at the same time, some reflection upon the structure of the part; viz. upon the nature of the inferor Membrain of the Nose, which is very thick, spongy, penitrable, actu­ally watered, and imbued with a vis­cous glewy Humor; which are all the requisite and necessary Circumstances for to make us think, that it contri­butes much to the formation of the Polypus, by reason its Porosities are so disposed, that they let pass nothing but the most crass and fungous Par­ticle of the Blood, which are very fit to produce some Excrescence.

True cause of its gene­ration.To explain rightly this generation, we must only admit a little more heat and intemperies in the Blood. The in­temperies encreases the motion, and exaltation of those viscous Particles, and the heat fixes and condenses them, by dissipating their humidity. Where­fore its not to be wondered at, if there abundance and profusion towards a spongy part, furnishes the Matter of a Polypus.

This Humor (I say) tho agitated, stops in the contexture of this Mem­brain, it the contexture of this Mem­brain, it extends the Vessels, blows up the Glands, dilates the excressory Channels, and obliges all these parts to rise in a Tumor, as well by its thick consistency, as too great intemperies; which makes it be no more in a condi­tion to pass through the Porosities of the Vessels that contain it, and so it congeals; and by a strange heat chan­ges into a fungous and carcinomatous Substance: So that by the addition and presence of a new matter, the Po­lypus grows insensible until it be in­tirely informed.

Of Polypus's, some are schirrous,Difference of Poly­pus's. some are schirrous, and some painful.

There are some which change into a cancerous Ulcer, and are most ordi­narily the consequences of some neg­lected venereal Distemper, whose lea­ven retires, and nestles in diverse cor­ners of the body, where it lieth a considerable time, without manifest­ing it self, or producing its effect.

Some of them are white, soft, and some red; the latter are the less ad­herent, and easiest cured. The opera­tion is never practised in the painful, nor schirrous. The painful are of dif­ficult cure; the schirrous endure best the action of caustic Medicines. Those that ulcerate, and become concerous, are sometimes conquered with such Remedies as are employ'd in the Pox. The cure of the soft, white, and red, particularly when they have a body, and are considerably grown, is easily brought to perfection by the Operati­on, or by Catheretic Medicines.

How to perform the Operation.The Operation consists in pinching the Polypus by the Roots, with a particular pair of Forceps, which we turn from one fide to another; and pulling by little and little, we tear off the Polypus with its roots. When you have ex­tracted [Page 189]it, the Patient snuffs up some Wine into his Nose; if a flux of Blood follow, you blow up some astringent Powders to absorb the Blood, and dry up the Ulcer. They are sometimes so considerable, that they occupy partly the narrow of the Throat, and so hinder the respiration and deglutition. In this occasion we endeavour to extract it through the Mouth with crooked Forceps.

CHAP. XXX. Of the Cataract.

Several o­pinions con­cerning the cause of a Cataract.THose that have treated of the Cataract, are divided in their Opinions concerning the cause that produces it. The one have maintain'd, That its only an obstruction of the apple of the Eye, form'd by the most viscous part of the watery Humor, which is shut up between the Cronea and Ʋvea. Others thinking to hit better, have advanced, That it's a Web which is form'd before the chri­staline Humor. However, I conceive, the Cataract to be formed after this manner.

The Au­thor's op­nion con­cerning the causes of a Cataract.All the World agree, That all the parts are form'd from the first moment of Conformation; and we can de­monstrate by these incontestable Prin­ciples, that there's never a Cist or Mem­brane generated absolutely-against Nature; and that these Cists and Ca­taracts which come so frequently, or to say better, which appear and become sensible to our eyes, are nothing else [Page 191]than the unfolding of the Membranes, and the little Pellicles which compose the parts; from which I conclude, that the Cataract begins only to be form'd by a little Pellicle which sepa­rates its self from the Christaline, and swims in the Aqueous Humor, which carries it from one place to another, according to the various motions we give to the eye.

The compo­sition of the chrystalline Humor.Which we may without pain con­ceive, if we consider that this Humor is nothing but a composition of seve­ral little Pellicles one laid upon ano­ther, and which may easily be taken asunder after it's boil'd; so that if we couch the Cataract when it's quite fra­med, you change, in a manner, the figure of the Chrystalline, that is to say, of convex it's made flat.

Now this Humor being no more so convex as it should be, there must a weak refraction follow from it, and consequently some confusion; I say,An incon­venience which al­ways follow upon the couching a Cataract. that the beams which come from eve­ry visible point of an object, and which enter into the eye at a certain distance, are never soon enough broken, by rea­son of the flatness of the Christalline, to be united when they come to the [Page 192] Retina, which causes us to see the ob­ject confusedly. We help this incon­venience by the means of a convex Glass, which regulates the distances that's necessary to make the refraction more favourable; and that the Retina may stand just at the reunion of the beams, which paint in Minature (up­on this Coat) the Image of the object: From whence it follows, That those whose Cataracts have been couched, never perceive objects so distinctly as others.

When first they begin to be form'd, and keep as yet their transparency, one sees the object, as if it were through a Cloud; and then we call them Suf­fusions. This little Pellicle changes colour and consistence, and cometh to be more or less thick, according to the nature of the Juice with which it's water'd, and the mixture of the Hu­mors which renders it opake and im­penetrable to the light;Different colours of Cataracts. this makes all the differences of Cataracts; there are some white, some of a lead colour, some green, yellow, pearl-colour'd; others of the colour of Sea-water, or of burnished Iron.

Other diffe­rences of Cataracts.Some are Lactaceous, as the white ones; some are more hardned, thin­ner, drier, and consequently more ca­pable to bear the Needle, as those like Pearl, or burnished Iron; on the con­trary the black, green, and yellow, are thick, extremely adherent, and very difficult to couch.

There are others which are hard like Parchment, and which have a sort of elastic virtue, which is the cause why after they are couched, they rise pre­sently again; the lactaceous or milky cannot resist the Needle, by reason of their little consistence and fluidity.

To know when a Cataract's ripe.You may know, when the Cataracts are in a condition to be couched, when in dilating the Pupilla, by rubbing the Eye, they remain fixt without any mo­tion.

If the beams of a Candle that pass through a Bottle full of Water, or a Chrystal, make the Patient perceive some Colours, it's a sign the Cataract is not quite form'd.

I do not speak here of the cause of the alteration in the Christalline, and of the different changes of the Cata­racts; I should have been obliged to speak of the Nature of Colours, but [Page 194]time hath not given me leave; there­fore I pass to the Operation.

How to per­form the O­peration.You place the Patient in a very light place, a Servant holds his Head be­hind, taking care to cover the sound Eye, that he may not turn aside; then bid the Patient turn his Eye towards his Nose. The OPERATOR with a round or flat Needle, having a han­dle, pierceth the conjunctiva near the Cornea at the little angle, and he pas­ses through it the point of the Needle. From the Aqueous Humor, you place it on the Cataract, and endeavour to couch it gently, keeping it a little while under. If the Patient distingui­shes the objects, it's a sign the Cata­ract is couched; but if it rise again, we are obliged to reiterate the Opera­tion, and to hold it longer down with the Needle. After which you apply on the Eye a Medecine made with A (que) Plantag. Rosar. & alb. ovi, with a Com­press and Handkerchief a-cross.

CHAP. XXXI. Of Wounds of the Head.

A simple Wound of the Head may be cu­red by Su­ture, &c.WE have made you observe in the beginning of this Treatise, that a simple Wound of the Head may be cured by the Suture, or by the uniting Bandage, unless the loss of substance be considerable.

But if the Wound be compound, that is, if besides the exterior parts, the Skull, Dura Mater, or the substance of the Brain it self be offended; the Phy­sitian and Chyrurgeon ought to sus­pend their Judgments, and recollect, at the same time, their Ideas and Knowledge, to prevent the ill Conse­quences of any Accident, whose cau­ses and symptoms are so dangerous, and very often Mortal.

The Skull may be fractured, the Dura Mater prick'd, cut, broken, torn, depressed; and the Brain cut, taken away, shaked, or filed with some extravasated matter.

The Skull may be hurt 2 ways. 5 Kinds of Hippocra­tes.The Skull may be hurt two ways, by Incision or Contusion. Hippocrates has established five kinds of Fra­ctures; which he hath called Fissure, Contusion, Incision, Depression, and Counter-Fissure.

Whether the Fissure be Oblique or Perpendicular;1. Fissure. it contains one only difference, which is to distinguish well whether there be but one, or both Tables fractured.

The Contusion is of two sorts;2. Contu­sion. the one doth not destroy the Continuity. Hippocrates called it Thlasis, vel Phlasis; it's nothing else but the forcing down of the Bone, without being broke.

Most inci­dent to Children.According to Hippocrates, it happens on the Skulls of Children, that have as yet the Bone very soft and tender. This Depression is after the same manner, as a bruise in a Pewter Pot.

The other kind of Contusion de­stroys the Continuity. In this the Bones are equal and contiguous. It's a single Fissure which always reaches beyond the place where the blow was given. If it be apparent, it's called Khegma: If it be insensible, it's called Trikismos, or Capillary Fissure.

The Incision is of three sorts,3. Incision. Eccope, Diacope, and Apokeparnismos; Eccope is a perpendicular Incision of the bone, without carrying off the piece, leaving nothing but a mark. HIPPO­CRATES calls it Hedra, the Latins Vestigium, or Sedes. Diacope is, when the blow lights obliquely, and goeth deep into the substance of the bone, without carrying it off: And Apokepar­nismos is, when the piece is intirely car­ried off.

The Depression destroyeth both the equality and contiguity of the bone;4. Depres­sion. HIPPOCRATES calls it Esphla­sis, or Enthlasis, depression or fracture with a splint; he hath established three kinds of it, Ecpiesma, Angisoma, and Camarosis.

Ecpiesma in Greek, is a depression of the Skull, where the Splints press the Dura Mater. Angisoma is a depression where the Splint separates it self, and passeth under the sound bone. Cama­rosis, or the Vault, is the third kind; this is divided in five sorts.

In the first, a part of the Bone bends down in breaking, and the o­ther turns up. In the second, the Bone boweth downward without any [Page 198]slit; this hapneth only to Children, as I have explain'd heretofore.

The third is a Depression, where the sides are forced down, the middle re­mains bent upwards, as a kind of Vault, leaving some hollowness under it.

The fourth riseth of it self; this is also when the Bones are only membra­nous, because they have a kind of spring or elastic virtue, till they begin to ossify.

Lastly, the fifth kind of Camarosis is, when the second Table is depress'd, and the outward return'd to its first state; this last only happens to In­fants, for Reasons which we have al­ledged.

The Contra Fissura which HIP­POCRATES hath established with­out ground,5. Counter-Fissure. hapneth in the same Bone, in divers Bones, and in different Ta­bles; in the same Bone, when the uppermost part is struck, and the lower broke in divers Bones, as when the blow is given on the occipital, and the coronal is broke; in different Tables when the first is struck, and the second broke.

These are three Chymeric Examples quite contrary to the structure of the part; if we see wounds of the head of this nature happen after Concussi­ons of the brain, it proceeds not from a Counterfissure, (as HIPPOCRA­TES pretends) but by true Re­lapses.

No such thing as a Counter-Fissure.It may easily be seen, that when a man has lost his senses, and hath re­cover'd them partly again, he is yet all giddy, and may after this manner relapse twice or thrice, and get new Wounds; for it's impossible that a Machin composed of several pieces as the Skull is, can break in a place oppo­site to that where it received the im­pression, it being certain that the blow dieth in all the circumference of the assemblage, and that the diploe hin­ders the shake from being communi­cated to the interior Table.

But without confounding and mi­staking our selves, we may say, that the Skull may be slit, depressed, fra­ctured, cut, or carried off.

If it be slit, the Fissure is visible, or almost insensible; but whether it be apparent or not, nothing is capable [Page 200]of giving us convincing marks that it penetrates, and that there is blood spilt on the dura mater, than these which succeed.

The use of Ink, the Rugine, and the Handkerchief in the mouth keep­ing one's breath, is absolutely useless, because the Diploe confounds and hin­ders one from seeing whether it rea­ches to the dura mater, or not; be­sides the practice of the Rugine will never be approved on by good Pra­ctitioners, not only because they do not give us any knowledge, but also because there remains a loss of substance, and deformity of the part.

If it be Depression, it presses with it the dura mater, and causeth several Accidents, which we will examine.

If it be fractured, either the Splin­ters are separated from the Cranium, or not; so by either way the dura mater may be compress'd, prick'd or torn, and the Brain hurt, or at least some Blood may be spill'd upon these parts.

In all these occasions, (I say) if the Fracture do not permit an unition of [Page 201]the shatter'd Bones, and vent given to the strange bodies, which might al­ter the dura mater, you must, without more ado, perform the Operation, (provided some ill Symptoms prece­ded) otherwise the Patient would die.

If it be cut or carried off either with, or without shattering the Bone; as for example, If the Incision pene­trate not, and there be only a part of the Bone separated, the consequences are not dangerous; but if it go deep, and there be some Splints separated that offend the dura mater, if we do not soon remedy it, the Patient is in danger of life.

Signs of inflamed dura ma­ter.If the dura mater be inflamed, ei­ther by diffused blood, or by some pricking, compression, tention, cut, or rupture, one presently feels pain and heaviness in that part, the Eyes grow puft up and inflamed, the Face red and swell'd, the diseased is drowsy with Fever, the Pulse hard with shi­verings, and blood comes often from the nose, ears and mouth, just as in great concussions of the brain.

We know that the dura mater is prick'd or torn, when there are some sharp pointed Splints, or rugged pie­ces of the bone which press it.

We are persuaded that it's compres­sed, &c. when the bones are depress'd and appli'd, as it were, against its sur­face, or that the broken pieces of bones are separated; or finally, that there is some extravasated blood which of­fends it.

We are convinc'd that it's cut, when it's caus'd by a sharp and cut­ting Instrument, and that the Fracture be of a great length; but if the bone be only crackt, and some blood be extravasated upon the dura mater, only those signs which I have describ'd, (and which I am going to explain) can give us certain evidences of it; I need not here repeat the explication of the pain.

Cause of the Heavi­ness.The Heaviness proceeds from the diffused blood upon the dura mater; for since she is to rise and follow the motions of the Brain, if the weight give her not liberty to obey, and the Brain find any resistance, her motion must be somewhat interrupted. Now [Page 203]seeing the motions of the Brain de­pends on that of the Arteries, the Impulsion of the Blood not being suf­ficient to elevate the substance of the Brian, and the weight upon it, its course must be slower in this part, and a heaviness must follow thereon.

Cause of puft-up and infla­med Eyes.The Eyes become puffed up an in­flamed; to explain this Phoenomena, you must only remember, that the Sinus's of the Basis of the Skull are only productions of the dura mater, and that they receive all the residuous blood that comes from the veins, which are distributed about the globe of the Eye. This being so, it's evi­dent, that if the dura mater be infla­med, she communicates it to the Si­nusses, and so opposes the return of the blood, which the veins are to pour into these little reservatories; and since the arterial blood still presses for­wards, the globe of the Eye, which is pressed by these two liquors, (by the reflux of one, and arrival of the other) must needs tumify and in­flame.

Not to confound the Inflamation of the Eye with that of the Eye-lids, you must consider, that that which happens to the globe of the Eye, proceeds from the Inflamation of the dura mater; and that of the Eye-lids, from the Infla­mation of the pericranium; for the in­terior membrane of the Eye-lids is a production of it.

We observe, that Inflamation of the Eyes doth sometimes not appear till the third, fourth or fifth day; this can come from nothing else, but from the long passage which there is be­tween the Inflamation of the Sinuffes, and the more or less progress it makes during that time.

Reasons of redness of the Face, &c.The Face groweth red, and puffed up, by reason the Inflamation of the dura mater obligeth one part of the blood that mounteth to the head through the internal Carotides, to spread on the place where they pierce the dura mater even to the neighbour­ing parts, and external Carotides; which is so much the more true, since we know that all parts of the Face swell and grow red in a very little time after any Inflamation, being wa­ter'd [Page 205]with a great many sanguiferous vessels; for the same reason the blood runs out of the nose, mouth and ears; and besides the blow that troubleth the whole oeconomy of the brain, it's to be presumed, that the blood which flows in abundance, some little cappil­lary vessels may be broken, by the great distentions they endure.

Reason of Drowsiness.The Patient is drowsy: To explain this kind of Lethargy, we must still have recourse to the Inflamation of the dura mater, and to the blood which is stopt in its Sinusses; or at least to the slowness of its motion, be it that the arterial blood is no more mingled with the grosser blood which they contain, or that the Inflamation in­creaseth. It happens that the weight of the blood which is pent up in these Sinusses, press the corpus callosum, and the nerves which are distributed about the organs of the senses, so by this means makes the head dull and heavy. You must observe, that this kind of Lethargy is not so deep as that which comes when the matter is diffused up­on the brain, as we shall speak of in its place.

Cause of the Fever.The Fever is caused by the inflama­tion and pain; for it's sufficient it but one drop of corrupted blood be con­vey'd into the whole mass to produce it.

Cause of hard Pulse.The Pulse is hard: To explain this Phoenomena, you must consider, that the dura mater, accompanieth the thick cords of the nerves is their passage, and the inflamation and great tention which she suffers, are capable to straiten all the little membranous sheaths which invelop them, and consequent­ly to hinder the spirits from flowing with that liberty into the fibres of the heart; so that its spring being weak­ned for want of this distribution, you must not wonder if it doth not force the blood into the Arteries with the same force and vigour as before, and if the Pulse be deep in this occa­sion.

Cause of the Shiver­ings.The Shiverings which accompany the Fever, can proceed from nothing else than the purulent matter, which causes the Impostumation; and from the disposition it has to be stopt, and prick the membranes, at the time when the veins are charged with it, to carry [Page 207]it to the heart, and from thence to all the parts; and seeing the most part of membranes are carnous, and each muscle hath its particular membranes, which is separated into a million of membranous fillets, which spread them­selves into the body of the muscle, and inchain all the little carnous fibres to one another, we have reason to be­lieve that the spirits running tumultu­ously into the fibres, occasioned by the motion which was imprinted in them, exciteth shiverings, which are so many little convulsive motions.

The Brain may be of­fended di­vers ways:The Brain may be hurt by a great commotion of the Head, by some blood diffused into its substance, or by some particular wound.

Signs of a Concussion of the Brain.If the Commotion be great, yet without any vessel broken, one falls to the ground with loss of the senses, feeling and motion, blood comes out of the nose, mouth and ears, the Ex­crements and Urine come out invo­luntary, with often swooning and vo­miting, sometimes soon, sometimes late.

Cause of falling down.If one falls down, it's an evident sign that not only the spirits are in disorder, but also that the commo­tion hath violated the nervous fillets of the corpus callosum, and that it has so rudely shaked the brain it self, that the course of the animal spirits hath been suppressed. Now since the spring and tonic motion of the muscles, that hold perpendicularly our bones toge­ther, and sustain the whole machin, depend only from the influence of the spirits which pass through the nerves into our muscles, if by any misfortune these cords come to slacken, and to lose some spirits by any mishap, the machin must needs fall.

Cause of loss of the Senses.The Senses are lost, by reason the course of the spirits is interrupted in the brain, and cannot repair to the organs of the Senses; now since the functions of the Senses depend on the course of the spirits in the nerves, it's no wonder if the exterior objects make no more impression upon our Senses, and we be no more in a con­dition to distinguish them. The Phae­nomena is a consequent of the prece­dent.

Cause of bleeding of the Nose, Mouth and Ears.The Blood flows out of the Nose, Mouth and Ears: To explain which Symptom, you must consider that these parts are rudely shaked in the time of the assault, that the blood and spirits are stopt in the brain, and that the great cords of the nerves, which at their passage out of the skull pass be­tween the branches o the carotidal and vertebral Arteries, imprint there such a violent motion at the time of the concussion, that they oblige the arterial blood to turn short, and flow into the external Carotides; so that these receiving almost all the blood which mount to the head, as well from the Inflamation, as from the shakings of the nerves, must needs break some capillary vessels.

The cause of involun­tary shed­ding of Urine and Excre­ments.The Excrements and Urine come forth against one's will, because the spirits repair no more in such cases to the sphincters of the Anus and Blad­der, than to other parts, which causes them to lose their spring, and permits the issue of those Excrements; the motions of the heart are weak and languishing, only for want of these same spirits.

Cause of Vomiting.One vomits at the very instant, or some time after: If one vomits pre­sently, it's a sign that the Commotion has not been one of the greatest, and the course of the spirits not long in­terrupted, since the impulse of the blood hath broke the sluce of them, and forced them to retake their course, and launch with so much quickness in­to the ventricle, that they excite this first vomiting, in which one renders nothing but Aliments.

But if the spirits be long retarded, it's a sign that the shake hath been very rude, and that the figure of the Brain is vitiated, since we see that when they are at full liberty, they run with pre­cipitation into the tunicles of the ven­tricles and intestines, which by their irregular and vermicular motions ob­lige the Bile, which runs into their cavity, to force the Pylorus, and pass into the stomach, from whence it's driven by the powerful contraction of its carnous fibres.

You must observe, that in this last Vomiting, where one renders Bile, it's [Page 211]much more violent than the first, and that the diseased lose their strength, vigor, and ordinary motion; these are the Accidents which immediately fol­low Concussion of the Brian.

Now it's very important to examine well those that happen when the Brain is hurt, and when any Blood or Pus is extravasated in its substance; some­times it is an effect of the Concussion that hath broken some vessel, and sometimes an effect of the blow, which hath prickt or cut the dura mater, or which has penetrated, or carried off some portion of the Brain; or finally, it's some Pus between the dura and pia mater, which is shed upon the Brian. In all these Causes the Fever comes with double Fits and Shiverings, accompa­nied with Vomiting, Convulsion, Deli­rium, Lethargy, and Apoplexy. And besides this croud of Symptoms, the Liver and Lungs often impostumate; which is known by a fixt pain on the Breast, or in the region of the Liver, and by reiterated Shiverings.

Cause of the redoubling of the Fe­ver.As for the Fever, with its Intermit­tings which come upon it, it's not hard to give Reasons for this extraordinary [Page 212]Fermentation, as soon as we be a little attentive upon the changes of corrup­tion, which happen to the matter that's diffused upon the substance of the Brain.

It's not to be doubted but that it grows impure, and more or less sour, according to the time it lieth there, that the veins are from time to time charged with it, and that a part passeth into the Heart, Lungs, and all the other Organs, which by their conti­nual motions form and grind them, as it were, into a thousand little parts, which lively hasten the impetuous course of the blood, and which cause the trouble and perturbation of the spirits, which march in disorder, which precipitate the motions of the heart, and increase the Fever; and when ever that strange matter which is offensive to the Brian, hath got some degree of corruption, and made it self fit to cir­culate with the venal blood; this matter, I say, receiving the same altera­tions and triturations which we have supposed sets the blood more sensibly in motion, and puts it in a much greater effervescency, on which depends [Page 213]the strength of the returns of the Fe­ver. After this manner, as often as the Blood is charg'd with it, the re­turns (which are a sit were periodi­cal) are renew'd.

From all the Reasons which I have alledged, it's easy to understand, that there are few parts or corners of the body where this purulent matter is not thrown; it pricks the Nerves, irritates the Membranes, transmits its action on the ventricle, nests its self sometimes in one muscle, sometimes in another, and causes shiverings, vomitings, and the vicissitude of irregular and convul­sive motions, which shew that the mass of blood is mightily suppress'd, the course of the spirits much agita­ted, so that Delirium and Lethargy must follow.

Cause of Delirium.The Delirium is an effect of the great inequality of the course of the blood in the redoublings of the Fever, and of the diffused matter, which be­gins to penetrate and corrupt the sub­stance of the Brain; the inequality of the course of the blood in the time of [Page 214]the redoublings, rules the irregularity of the course of the spirits in the parts, and the extravasated matter gnaws by its acrimony the vessels and nervous fibres of the white part, so puts to the rout the spirits into the muscles, or­gans of the senses, and in the passages of the brain, where the Idea's are weakned with irregularity and con­fusion.

Cause of the Lethar­gy.The Lethargy follows, when ever there's much blood spilt upon the brain, being in its last degree of mo­tion and exaltation, the weight of the extravasated blood presses the brain, and the quick motion of the blood causes the courser particles to separate from the fine ones, that they stick to the pores of the glands, and stop the passage of the spirits; so that the brain finding it self oppress'd with the weight of the matter, the Patient falls into a profound drowsiness; but in the time that this extravasated matter dissipates its self, the courser particles, which are so many sluces, be put out of order, by the impulsion of new blood, the spirits fly out into the parts [Page 215]with so much vivacity and confusion, that they renew the Phrensy, which succeeds the Lethargy, just as the Le­thargy succeeds the Delirium; you must observe that in this kind of Le­thargy, the Eyes are sometimes open and troubled.

Lastly, It happens that the blood hastens with so great impetuosity to the brain, and that the extravasated matter gathereth there so abundantly, that it interrupts, by its weight, the course of the spirits, and constrain the Sinusses of the dura mater every where to overflow,Cause of Apoplexy. so that the Arteries being unable to empty themselves either into the Veins or Sinusses, the brain finds it self so press'd on all sides, that the wounded falls into an Apoplexy, which makes us know that Death is not far off, and that there is no more help.

How the Liver or Lungs im­postumate in Wounds of the Head.The Liver of Lungs impostumate in great Wounds of the Head, by the ar­rival of Pus, which comes from the Brain, of which the mass of blood hath got some impressions; we have [Page 216]in the Chapter of the Empiema given an account of the Formation of an Impostume of the Lungs.

For to have an Idea of that of the Liver, one cannot ground upon more solid Reasons, than to examine its structure in relation to that of other Viscera, which are contain'd in the ABDOMEN.

What the Liver is.The LIVER is the biggest, and most considerable of all the Viscera; it's a conglomerate Gland, deprived of all carnous fibres, water'd by a pro­digious number of sanguiferous Ves­sels, among which the vena porta doth the office of an Artery, and the Circu­lation consequently must be very slow there; besides, we are sure that the little Glands which compose it, separate a liquor, which is extremely glewy and viscous of its own nature, which are all the requisite and necessary con­ditions to retain a matter, which al­ready hath a great tendency to stop and cause some disorder; so that after the heart, and the other organs have prepared and put it in a condition to [Page 217]produce its effect, it diffuseth it self in­to the whole mass of blood; and be­ing the Liver receiveth a great number of vessels, it followeth that the He­patic Artery, and Vena Porta, (which are distributed through its whole ca­pacity) having cram'd every glandu­lous grain with it, according to its dis­position and different alterations which it receives it this Parenchima, it putrefies it, or makes it schirrous: You must observe, that the Hydrocephalus is al­most always followed with the same accident, and that in these kinds of Impostumations the shiverings cease most commonly some days before death.

We suspect that the Brain is alter'd when the Fracture is big, and some of the Animal Functions are depraved; for since our Actions depend on the Functions of the Brain, when ever those are hindred, they shew that the Brian is offended: You must observe, that in all I have proposed concerning Wounds of the Brain, I have not comprehended the hind-part of the Brian; I am throughly persuaded that [Page 218]an Animal dieth presently,Wounds of the hinder part of the Brain in­evitably mortal. as soon as the cineritious substance of the hind part of the Brian be prickt, carried off, or compress'd, because the nerves that furnish us with spirits for the functions of the vital and natural parts, take immediately their origin from thence: This is doubtless the reason that hath obliged Nature to take so much care and precaution, to preserve this part so precious to life; she has plac'd it under two posterior advances of the Brain, for fear it might be interessed in the great havocks which happen in divers places of the Head; she hath separated it from the Brain, by a mem­branous Inclosure very strong and thick to hinder it, lest in any concus­sion it might be compress'd by its two posterior Lobes. Lastly, Nature hath cover'd it behind with a piece of very hard, thick, and irregular Bone, for a defence against outward injuries, and to secure it from all that may be hurt­ful.

Prognostics of Wounds of the Brain.You must observe, that the more Wounds approach to the medulla oblon­gata, the more mortal they be, because [Page 219]all the nervous fillaments of the white substance join there together, and a considerable quantity of them is divided.

All this has regard to the Progno­stics of Wounds of the Head; but to speak of them more largely, we have only to consider the nature of the Wound, and to examine their Acci­dents.

If the Fracture be made with a cut­ting Instrument, it's not so dangerous as one made by a pricking, or that which is caused by a Fall, or contusing Instrument, which cannot break the Skull without great violence, upon which follows always a great Commo­tion; but if it be made with Gun­shot, it's always mortal, unless the Bullet carry off only some portion of the Cranium, without offending the brain.

We know that contused Wounds of the Head are simple or compound; the latter are more dangerous, because ac­companied with Fracture. If a simple [Page 220]Wound with Contusion be only super­ficial, it's cured with Resolutive Me­dicines, as an Ecchimosis. If it pene­trate, it requireth Superation. If the Pericranium be rumpled, and that it suffers some divulsions, the eye-lids inflame, and there comes some Acci­dents upon it, as upon Wounds of the Tendons; to remedy this Inconve­nience, we have nothing more to do, but to cut the Pericranium to the bone, and to dress the Wound after the ordi­nary manner. Sometimes it hapneth that the Skull is fractured, the Tegu­ments being undivided; the reason is, that being made of a hard and brittle matter, it cannot resist the fury of the blow, as bodies which are pli­able do, and it can break even as a Sword, which in its Scabbard may be broken, without endangering the Scab­bard; in this case we make an Incision over the Fracture, more or less, as is convenient, with this circumstance, that we lean not too hard with the Knife upon the fractur'd part, especially if it be a considerable one, lest you offend the brain.

The Prognostics also of wounds of the Head depend on the good or ill disposition of the Patient, the vio­lence of the blow, and the strength of him that gave it with more or less force.

A Fracture that keeps its equality, is not so dangerous as one of several pieces, which press or prick the parts that are under them, particularly when they are engaged or lie one up­on another, because the compression is much stronger, and the Dura ma­ter suffers more: Besides, when the Skull is so broken, it's always a sign that the Blow hath been violent enough to shake the Brain.Wounds of the Dura mater very dan­gerous. If the Dura mater be broken by the Splints, the wounds are very pernicious, be­cause of the Blood spilt upon the Brain, and of the Tention and In­flammation it suffers. The Inflam­mation of this Membrane tends often to Mortification, because of its hard­ness and sensibility.

Great Concussi­ons hardly cured.Concussions of the Brain are sel­dom cured if great, because it's im­possible to make the Extravasated Matter to come out.

Vomiting upon Di­lirium and Le­thargy mortal.Observe, That if Vomiting come upon it in time of the Dilirium and Lethargy, it's a mortal sign; and if Irregular horrors or shiverings come, it's a sign that the Extravasated Blood putrifies and corrupts the white sub­stance of the Brain.

Wounds of the Cortical part of the Brain are not always mortal, es­pecially when the bigness of the A­perture facilitates the entry of Medi­cines, unless the Brain has been too rudely shaked; whereas if they pe­netrate to the white subtance, they are always mortal, not only because the principle of the Nerves are hurt, but also because we cannot penetrate unto that substance without cutting thick Branches of Arteries which are concealed in the Anfractuosities of the Brain, from thence cometh the Extravasation of Blood which admits of no cure.

If the wounds of the Skull, consi­dered in themselves, had any Indica­tion like other Fractures, it would be Re-union; but seeing the Skull cannot be broke without the inferior parts receiving some troublesom im­pression, we must trepan there to in­troduce [Page 223]Medicines, and as soon as we know that the Skull is broke, we ought not to defer the operation. Therefore, whether it be split or broken, it's always true to say, that the Dura mater is concerned.

The Fissure causeth a tention, be­cause the Dura mater, is ordinarily adherent to the Skull, by all the Ves­sels of Communication, and those which carry the nourishment to the Inferior Table, besides the little Fibres which pass through the Sutures, which is particularly observed in young People. This Tention is soon fol­lowed by an Inflammation, for as much as the Vessels cannot long re­main stretcht without breaking, and spilling of Blood, which by its abode inflames the Membrane, and if the Inflammation increase, it often Gan­greens.

When the Trepans to be usedIf in Fracture of the Skull the Splints offend the Dura mater, either by pressing, pricking, or rending it, we must needs trepan to prevent ac­cidents, or to diminish them, to take away the Extravasated Blood, sepa­rate the Pieces which hurt it, and to have liberty to apply there convenient Medicines.

It's therefore a Rule which we must follow, that if the two Tables be broke, we must always come to the Operation, though there appear no accident, for besides that the Ope­ration is not dangerous,The Ope­ration not dange­rous. we have the advantage to hinder symptomes; whereas if the Skull be not alter'd, and some troublesome symptomes happen, we must Trepan, because the Skull being found, it's easie to see, that the symptomes which follow are the consequences of some ill Con­cussion of the Brain; besides, we know neither the place, nor existance of the Matter, nor where the Brain suffers. However some say, that provided the Patient can fix with his Hand the place where he feels pain and heaviness, we ought to apply the Trepan there;Caution. which nevertheless the most famous Practitioners dare not undertake, lest they should find nothing there, and so pass for Rash and Inconsiderate.How to Cure Wounds of the Dura mater. To Cure Wounds of the Dura mater, we must Examine their Nature and Cause, we must Bleed to diminish the Inflammati­on, and apply upon the tumified and inflamed part Ol. Amigdal. Dulc. Quor. [Page 225]Violar. Lillior. Aquatic. which we must mix with some Spirit. Vini: This at­tenuates the Blood that's congealed, and the other softens and relaxes the Fibres of the Dura mater. You must also endeavour to make the Suppura­tion of the Exterior Wound very copious, that the Vessels of the Dura mater which have communication with the Exterior parts may easily disengage themselves.

A great Concussion mortal.As to what regards the affections of the Brain, we know that a great Concussion is mortal, and a little one cured with Bleeding and other Universal Remedies. Extravasation of the Blood is somewhat more dan­gerous, and it seldom happens that the Vessels are broke without the Brain receiving a great commotion: In that case we have no other help than Bleeding, and general Medi­cines, observing a very exact Diet. For sometimes in taking these pre­cautions, Nature resolveth the Ex­travasated Blood, and the Fever grow­eth less.

It's not the same thing in Wounds of the Brain, where the Skull is car­ried off, and where there is Extra­vasated [Page 226]Blood, I have said its neces­sary to Trepan, if the Aperture per­mits us not to elevate the Pieces a­bove the Extravasated Blood, and conveniently apply Medicines. We know by Experience, that several Pa­tients have been cured, and yet a part of the substance of the Brain carried off; It's true, that Wounds which enter only the Cineritious or Cortical part of the Brain, may be cured, provided the Patient be o­therwise well disposed, whereas those of the white substance of the Brain are mortal, for Reasons which we have given.

CHAP. XXXII. Of the Operation of the Trepan.

BEfore we give a Description of the Operation, it's important to examine all the Circumstances ne­cessary to render the Operation suc­cessful. It consists in Piercing the Skull, and to make an Aperture near the Fractured part. To execute these two Intentions, it's necessary to know whether all the parts of the Head can endure the Trepan; I speak not here of the Bones which are most easie to break, those that know the Asteology are instructed there­in.

If the Fissure be simple, apply your Trepan just near the Cleft, if it be very little, one might Trepan upon the Fissure it self, to give an easier vent to the Matter, neverthe­less with this Circumstance,A Cauti­on to be observed in Tre­paning. which is to Anticipate a little upon the side that hath the most strength; which must be observed in all other places of the Skull.

If you should meet with any strange body, that were forced down into the body of the Bone, so that it could not be pulled out, you must apply the Crown of the Trepan upon the strange Body to carry off the Piece.

If it be a considerable Fracture, where a part is forced down, you Trepan upon that part where you think most convenient to elevate the Bone, nevertheless you must apply the Trepan upon a part that's firm enough to sustain it without breaking it down. If the first Aperture be not sufficient to lift up all Pieces, you must make a second and a third if it be necessary.

We must not Tre­pan the Sutures.We never Trepan upon the Sutures, especially upon that place call'd Fon­tanella, lest we break the Vessels which pass a cross, and tear the Dura mater which adheres to the Skull, especially in its windings, so that the Blood which is extravasated on one side, hath no communication with the o­ther: Wherefore if the Fracture should cross a Suture, and anticipate upon two Bones, you must Trepan upon both sides.

Trepaning is also forbidden di­rectly in the mid'st of the Coronal and Occipital Bone, especially to­wards their Inferior part, by reason of their Spina's where the producti­ons of the Dura mater are fastned, which are let in.

We Trepan not upon the Longi­tudinal Sinues lest the suppuration should open them, which would cause a dangerous Hemorrhagy.

Neither must we Trepan upon the Eyebrows, because of the Sinus Frontalis, and of their Cavities, which are lin'd with a considerable thick Membrane, deckt with an infinite number of Glands, which separate a Viscous Humour that actually fills these Cavities, which makes that the Wounds of these parts do long sup­purate. Behold these are all the cases or places of the Skull where the Tre­pan is to be rejected, you may bold­ly use it in all other parts. The An­cients made a difficulty to Trepan at its inferior part, because of the weight of the Brain, and the propen­sion it has to get out, but it's a Chy­merical Error, being the situation may remedy this disorder. When [Page 230]ever you put the Operation in Pra­ctice, this must be observed, viz. That the place where the Trepan hath been applied, must always be elevated or the highest.

What manner of Incisi­ons conve­nient.We must now speak of the Instru­ments of the Trepan, and of the Means to use them, but before, it's proper to know after what manner the Incisions of the Teguments and Flesh are made.

If upon the Temples.If it be upon the Temporal Muscle, some make the Incision in the shape of the Cipher 7, or of the Letter V, which they mark with the Nail or Ink, but I do not believe it can be done after this manner with­out destroying the Fibres. It's there­fore fitter to imitate their Rectitude, and to make if somewhat large to have the liberty of placing the Tre­pan, in dilating the lips of the Wound; Others recommend to make it every where else in form of a Cross, but if the Longitudinal Incision, or in form of the Letter T, suffice to discover the Fracture, and place the Trepan, you must absolutely reject that of the Cross; If the Wound be on the Forehead, you must fol­low the Wrinkles of it.

The Peri­cranium covers not the Tem­poral Muscle as has been thought.As to what concerns the Tempo­ral Muscle, it hath hitherto been be­lieved, that its Wounds are dange­rous, being covered with the Peri­cranium, but it's known that this Mem­brane exactly covers the Temporal Bone, even as in all other places of the Skull; and that the part which has been taken for the Pericranium, is a lengthening of the Aponevrosis of the Frontal and Occipital Muscles, which frame by their re-union a kind of Tendonous Cover which antici­pates upon the greatest part of that Muscle, and which being prickt or rumpled with some blow, causeth the same accidents which accompany Wounds of the other Tendons; Of the rest the Wounds of this Muscle are no more to be feared than those of another. I pass to the Circumstances of the Operation.

Let's now suppose a Wound at the Superior part of the Parietal Bone. You must first probe it; If you find the Skull discovered, and the Aper­ture not big enough, you dilate it even to the Bone to examine the Fracture, and you fill the Wound with dry Lint, to absorb the Blood, [Page 232]which might hinder the fight whe­ther it be of danger. If any Artery should bleed much, you would be forc'd to make a Ligature, and leave the Wound till next day.

If the Fracture be considerable, and some splints of the Bone forc'd down, so that you were obliged to elevate them, it's the part of a pru­dent Surgeon to leave the Dressings for 5 or 6 hours till the Hemorrhagy be a little stop'd, and then he may choose a fit place to apply the Tre­pan.

How to use the Trepan.When you have fixt on a place, you stop the Patients Ears with Cot­ton, lay his Head on some firm place, scrape the Pericranium off, lest you tear it with the Teeth of the Saw, you cover the lips of the Wound, then you choose a Crown of a Tre­pan proportionable to the hole you intend to make, but first you make a little hole with the Perforative Tre­pan, to fasten the Pyramid which you put into the Crown; afterwards you turn the Trepan, and saw the Skull, and when the Trepan hath taken suffi­cient hold, you take the Pyramid off, lest you hurt the Dura mater, [Page 233]then you go on sawing the Skull, tak­ing care from time to time to cleanse the Teeth, and the hole you have made, and observe whether you saw equally, so you finish to pierce the Scull by several turns; if you per­ceive that the Crown penetrates more in one place than another, you lean more on that side which is not so much penetrated to equalize the Aperture.

You know that you are come to the Diploe when the Teeth of the Trepan are Bloody, and seeing the Interior Table of the Scull is much thinner than the Exterior, and often adherent to the Dura mater, espe­pecially in young People, if you should not take care to turn the Tre­pan softly, and to shake the Piece at every turn of the Saw, you would be in danger to hurt the Dura mater; When the Piece is disengaged, you take it off with the Piercer or Myrtle Leaf, and you scrape the circumfe­rence of the Aperture with the Len­nicular Instrument, with which you press a little the Dura mater, to faci­litate the Issue of the Extravasated Blood, and to introduce more com­modiously [Page 134]the necessary Instruments, as the Levatory to elevate the Pieces that were depressed.

If the Piece be extreamly adhe­rent to the Dura mater, you separate it with the Myrtle Leaf: Several Practitioners recommend to let it alone till its fall be procured by Sup­puration; But since these ties are only in young People, who have these parts always moist and relaxt, they may be easily separated with the Spa­tula without any violence.

When the Piece is taking off, we ordinarily give vent to the Extrava­sated Blood upon the Dura mater in bidding the Patient shut his Mouth and Nose, and keep his Breath.

This ingenious manner of pressing out the Blood, is an effect of the Expansion of the Lungs, and level­ling of the Diaphragm, which presses the Descending Aorta that passes be­tween its Tendons, and forces the Blood to flow into the Ascending Aorta, and so mount to the Head by the Vertebral and Carotid Arteries with such rapidity, that the Brain riseth with so much strength as to oblige the Extravasated Blood to flow [Page 235]through the Aperture of the Skull, or to appear at the Passage so that it may be absorb'd with ease.

How to dress the Dura mater.Having disingag'd the Dura mater of the Burthen which oppressed it, you you wet a little piece of fine Linnen in Mel Rosar with Spirit. Vini, which you introduce between the Skull and Dura mater, as well for to Humect and dry as to resolve the Matter: You pass through the middest of it a Thread which keeps it from going too far under. This is call'd Sindon, it must be somewhat bigger than the Aperture, that the Medicines may have room to extend themselves on the neighbouring parts, and the Dura mater not to be hurt in the Motions of the Brain against the edges of the Skull: Upon this Sindon you put another of Lint dipt in the same Me­dicine, you fill the rest of the hole with dry Lint, and cover the Bone with it, and the rest of the wound for the first days is drest with Dige­stives able to procure a strong Sup­puration.

Great Suppura­tion very conveni­ent.We have already made you ob­serve, that great Suppuration of the Exterior Wound very much contri­butes [Page 236]towards the easing of the Dura mater, through the frequent com­merce that is between the Exterior and Inferior Vessels.

You shave the Head for to Embio­cate with Ol. Rosat. & Spirit. Vini, you make use of Emplast. De Betonica. or Andreas e Cruce, of a Compress temper'd in strong Wine, and useful Bandage; you dress the Wound the following days with the same care.

If the Splints be separated you take them away, if they stick to the Skull and cannot be replaced, you cut them off with the Incisive Pincers.

The Dura mater is sometimes so inflamed, that it rises beyond the A­perture of the Skull in spight of all the precautions that one can take, and seeing it's dangerous to Trepan too much, nothing but Bleeding, Clysters, and an exact Dyet can stop the progress of the Inflammation.

If Blood or Matter be got between the Membranes, there's no other re­medy than to give vent to the Mat­ter. To execute which design with prudence you arm a Lancet,How to penetrate the Dura mater. and dexterously open the Dura mater with­out the knowledge of the by-standers.

When the Dura mater and the Brain are hurt, there arises very often (in the last days) upon it a Fungus, like a Mushroom, which increaseth more or less according as the Matter which contributes to its generation is more or less unctuous.

Malpi­gius's Opinion.The Famous MALPIGIUS pre­tends, that the displacing the Glands of the Brain, and the little Nervous Pipes, frame this Excrescence. But without running to the disordering of the Glands, is it not more reasonable to believe, that it's bred from the abundance of the Fat,Cause of a Fungus. and Oleagi­nous Matters, with which the Brain is actually water'd, as we have suffi­ciently proved in several places of this Treatise; which Experience also every day shews us in those upon whose Dura mater Oyls are outward­ly applied.

In this Inconvenience you must dry it with Spirit of Wine, or Tinct. Aloes, which dissipates its Humidity, and forsake the use of Oyntments.

How to Consume a Fungus.If these Remedies be not sufficient to extirpate the Fungus, use the soft­est Catheretic's, as Turpentine in Pouder, Pul. Irid. Florent. Alurn. [Page 238]Ustum. some time you may apply Precept. Rub. In using these Powders the Flesh must be also a little com­press'd, or it will not be consumed.

After these Medicines have per­form'd their vertue, a Decoct. of Traumatic Herbs in White Wine is very advantageous, to which add Mel. Rosat. more or less according as it's necessary to Humect or Dry up.

You must correct the Air of the Pa­tient's Chamber by the use of Fire, es­pecially when you dress him, & apply the Medicines as warm as you can.

When the Flesh is quick and firm, you must maintain it in that conditi­on, but when it's too soft you must compress it, or use more drying Re­medies.

Whilst you are curing the Interior after this manner, you must Exter­nally use the best Traumatics, and apply upon the Bone such Remedies as hasten the Exfoliation, as Spirit. Vini, in which Euphorb. is infused, which is admirable to hasten Exfolia­tion: It must be always used before the Flesh which grows upon the Brain surmount the Aperture, and according to the nature of the Ac­cidents [Page 239]which happen, general Me­dicines ought to accompany the Topics.

CHAP. XXXIII. Of the Anevrisma.

Two sorts of Anev­risma's.AN Anevrisma is a Preternatural Tumor form'd by the dilata­tion of the Artery, or by the Rup­ture of its Tumicles, which makes two kind of Anevrisma's, the true and false. The true one is that which doth not abandon the Pipe of the Artery,True and false. and which hath correspon­dence with the Blood, which the Heart sends continually there: On the contrary the false possesses the nigh parts, and hath no communi­cation at all with the Arterial Blood.

Internal cause of a true A­nevris­ma.Concerning the Internal cause of the true Anevrisma, we can attribute it to nothing but to the action of a sharp and corrosive Humour which is separated from the Glands that are spread about the Vessels, and which insensibly gnaw the outward Coat of [Page 240]the Artery, so that the Blood by re­iterated shakings disposes the Inferior Tunicle to extend and dilate it self, and after several Impulsions not being in a condition of resisting its motion, it gives way, and obeys till at last a Tumour is form'd, which is call'd an Anevrism. Thus I conceive all sorts of Anevrism's to be form'd, which naturally happen on the Neck, Arms, and several other parts.

We also observe, that these kinds of Tumours possess rather Lean and Atrophiated Persons, whose Blood is loaden with salt, than those that are fat and pampered.

External causes of a true Anev­risma.The External causes of a true A­nevrisma cometh from a Punction, made on the Exterior Coat of the Artery with a Lancet, Sword, or other like Instrument, or from some Blow, &c. or finally from the strong Im­pression which sharp and Corrosive Medicines, or Humours, which lurk about the Vessels, make upon the same Exteriour Coat; it's easie to comprehend that all these causes are capable of weakening the Pipe of the Artery, and the Blood beating without intermission, extends, and [Page 241]forceth outwardly the Pipe, and so produceth a Tumour.

Cause of the false Anevris­ma.The false Anevrisma is caused by the total ruption of the Tunicles of the Artery, which gives vent to the Blood to Extravasate it self between the Porosities of the Flesh and Skin, and so forms a Tumour, which is followed by troublesom accidents, because the Extravasated Blood being no more in motion, ferments and suffers alteration, which is almost al­ways followed by the Marks of Mor­tification: These two kinds of Anev­risma's increase more or less, accord­ing as the action of the sharp Juices, Contusion, Aperture of the Vessel, and Impulsion of the Blood are more or less considerable.

Signs of a true A­nevris­ma.The Signs of the true Anevrisma are sensible pulsation of the Tumour, and its softness, when it's pressed with the Fingers it disappears at the same time, but as soon as you give over pressing, it comes again into its first state. The colour of the Skin is not changed; because the Blood which maintains the Tumour keeps its li­quidness, by the meeting and mix­ture of new Blood whose motion is [Page 242]continual. In its least increase or bigness, it's commonly as big as a Nut, or Egg at most; some Authors assure us, that these Tumours aug­ment sometimes so much that they break, nevertheless we know that some have kept them all their lives; and that in most Persons who are troubled with them, the part of the weaken'd Artery becomes so hard and callous, that it resists all the ef­forts one can make.

Cause of Indura­tion of the Artery.Though this Ossification of the Ar­tery seem very difficult to explain, one may nevertheless believe, that the saline, pungent, and most ex­alted particles of the Blood, pene­trate the lesser porosites of the Fibres of its Tunicle, and they post and mingle themselves with the nourish­ing Juice of the Artery, and so con­tribute towards its Ossification.

But the reason which to me seem­eth most evident, and best ground­ed, is, that the Blood which main­tains the Anovrism, and which is in a continual fermentation, must by its motion increase the heat of the part which insensibly dryeth and hardens the Fibres of the dilated part in dis­sipating [Page 243]and rarefying the humidity which waters and makes them dull: That which fortifies more this thought, is, that the Aorta groweth bony (sometimes in old People) at its exit from the left Ventricle of the Heart, either through the little heat that's left there, dries it, or because their Blood hath lost its Viscosity which is necessary to preserve its spring: Notwithstanding Experience shews us, that it's Ossified in some Persons.

Signs of the False Anev­rism.The Signs of the False Anevrism are opposite to those of the True; In the False the Pulsation of the Ar­tery is very deep; the Skin almost livid, the Tumour is not so high, nor round as in the true one, but it takes up more room, it giveth not way so easily in touching as the true one. The most convincing signs of the Arteries being opened, is, when the Blood comes out impetuously and by jumps, which convinces us, that its motion is continual and unequal.

This inequality of the course of the Blood proceeds from two contrary motions; the first depends on the strong constriction of the Ventricles [Page 244]of the Heart, and the second from the spring of the Arteries. But be­ing the Impulsion of the one is much stronger than that of the other, it happens, that as the Heart driveth the Blood vigorously forward in the time of the Systole, the Arteries by their Elastic Virtue beat and drive it back weekly in the Diastole, which proves the irregularity and continua­tion of its motion.

Signs of a Wounded Artery.If you perceive that you have un­luckily opened one of the Tunicles of the Artery, which is known by the resistance of the blow, by the ele­vation and the violence of its pulsa­tion, which is presently communi­cated to the Vein, and which obliges the Venal Blood to come out by jumps as the Arterial Blood, but is not so brisk, lively, or shining, and is less swift; you must have recourse to Phlebotomy which impedes its motion, and by this means hinders the progress of the Tumour, you apply thereon a little Compress, in which you put half a Bean, which presses only the Aperture, over that you lay another a little bigger, after this manner you apply several Com­presses [Page 245]gradually bigger, which you keep on with a fitting Bandage, and on the neighbouring parts lay good defensatives.

A certain piece of Money.There are some which make use of a Double to compress the Aper­ture of the Artery, but this practice is not approved, by reason that be­ing obliged to tie the Bandage strait, the Double taking more room than half a Bean, which only compresses the Aperture, it's to be feared lest the circumference of the wounded part Gangreen; but to supply the want of this strong compression, you place at the Internal part of the Arm, all along the thick Vessels, a Longitudinal Compress which you secure with the Creaping Bandage.

This Compress produceth very good effects; for besides that it mo­derates the rapid stream of the Blood, and by this means you may avoid tying the band too tite, it helps also the reunion of the Artery, be­cause the Impulsion of the Blood being only weak, the Aperture se­parates very little. When the Pa­tient begins to have strength, you must reiterate Bleeding, for reasons [Page 246]we have alledged, you take off the Dressing as late as you can, because in a very little time it increases con­siderably.

But the Accidents which follow upon a false Anevrism are ordinarily violent and cruel, being Gangreen and Mortification are its mournful Consequences, you must not differ the Operation unless the use of the Compresses which are applied there, and other precautions which must be taken, stop its progress, or the Re­solutive Medicines which we use, make the Extravasated Blood re-enter again in commerce with the Liquor, or be discust by insensible perspira­tion, in attenuating and rarefying its Molicule lying between the poro­sites of the flesh; on the contrary a true Anevrism may be kept all ones life time, or at least some conside­rable time; for which reason one may prolong the Operation in laying on the Tumour some Compresses for­tified with a Bandage, without the Patients being in any danger, unless he resolve to endure the Operation. This, as hath been said, grows to a certain bigness, whereas the pro­gress [Page 247]of the false is not limited: Lastly, if in spight of all precauti­on, and all the care that can be taken in both kinds, you succeed not, you are obliged to perform the Opera­tion.

CHAP. XXXIV. Of the Operation of the Anevrism.

Three ways of the Ope­ration of an A­nevrism. 1. By the Vitriolic Button.THis Operation is practised three different ways. The first is by the Vitriol Button, but the worst is, that as the Vitriolic particles melt, they spread themselves upon the Li­gaments, and adjacent Tendons, which they carry off, rend, and cauterise, till at last the Patient is lamed, being the part groweth in­capable of its ordinary motions.

The second is to disgorge the Tu­mour before you make the Ligature of the Vessel, but behold, as I think,2 the surest method.

The Patient being plac't.3 you lay on the midst of the Arm a strong Compress, sustained with a Ligature [Page 248]through which you pass the Tourni­ket, making several turns, by which means you benum the Arm, stopping the passage of the Blood and Spirits.

The Surgeon Inciseth with a Lan­cet the Tumour following the length of the Artery, which must be sepa­rated from the Nerve, to have the liberty of tying the Artery half a Fingers breadth above the Aperture with a little strong wax't Thread.

You must observe, that in a true Anevrism the Tumour regulates the place where you must make the Li­gature, whereas in the false we are obliged to loose the Turniket to know positively whence the Blood comes, which is the most important circumstance of the Operation, for to stay the Blood, and to avoid mak­ing the Ligature upon the Aperture of the Vessel, instead of making it a little higher, because the Blood by its impulsion would not fail to dilate the weaken'd part, and to bleed afresh. For this purpose you pass a Needle over the pipe of the Artery, make first a single knot, on which you place a little Compress which you fasten with two other knots.

Most make another knot in the lower part of the Artery, because of the Branches of communication, and since it being a precaution not to be despised, one may use it.

The Ligature being made, you loose the Tourniket: If the Blood be well stopt, you open the Tumour to empty the Blood, and fill it with Dorsels arm'd with Astringent Powders, as Vitriol. alb. to consume the Bag more easily you cover the rest of the wound with Boulsters, accom­panied with a Plaister, Embrocation of Ol. Rosar. Defensatives all along the Arm, with Compresses temper'd in strong warm Wine, with the Bandage.

Some time afterwards you must Bleed the Patient, if his strength permit, you stay two or three days without taking off the Dressings, and you leave the Dossels at the bottom of the Sac 3 or 4 days longer, lest in taking them out you bleed afresh, and procure a fresh suppuration.

The situation of the Arm, which seems a thing of little consequence, must nevertheless be regarded as very advantageous for furthering the cure. [Page 250]The Arm must be a little bended, and the Hand elevated on the Pillow, that the circulation be more free: But you must particularly recom­mend the Diseased to bow and stretch it from time to time. We daily see that several become lame for not having moved the Arm or Leg dur­ing such Indispositions. The cause of this accident comes from the little motion of the slimy matter which be­daubs the Joints: This Slime is of the consistence of the White of an Egg, and which transpires from the Ligaments and Glands of the Joynts, serving to entertain the supple Li­gaments, and to smooth the shining Cartilages, as well to facilitate the motion, as to hinder the parts from being wasted by their continual at­trition, but from the moment that this Matter is at rest, and no more fluid or liquid by the diversities of motion, it groweth thick and hard by the heat of the part; so that the Ligaments and Cartilages being no more humected by that Liquor, they dry up, loose their Elastic Virtue and Humidity, till at last they grow in­capable of motion.

Sometimes it happens in old Rot­tenness and Fistula's of the Joynts, that the Purulent and Malign Mat­ters gnaw the Ligaments and Carti­lages, and gives occasion to the Sa­line Juice, which exuds from the body Fibres, to unite the extremity of the two Bones, and frame a kind of Anchilose, which is much more defectuous than the precedent.

CHAP. XXXV. Of Gangrene and Sphacel, which oc­casions the Amputation.

SEveral Authors have treated of the Gangrene, particularly Willis, Etmuller, and Silvius; and I believe no body doubts, but that all what­ever our new Discoverers have ad­vanced upon this Subject in their Exercises, is nothing but a perpetual pillage of what these great Men had spoken. To speak of it methodi­cally, we must first give an Idea of the Vivification of the parts, and of the Mortification, which is its op­posite, [Page 252]we must relate all particu­lars which cause a Gangrene, and seek all the means to illuminate them with Reasons grounded on the Oe­conomy of the Blood, and upon some Observations which Experience Au­thorises.

Cause of Vivifica­tion.To know how the parts are Vivi­fied, you must consider that the heat and life of Animals consists only in the motion and fermentation of the principles of the Blood, that this Fermentation and Motion, as well Circular as Intestine, are entertain'd by the pulsation of the Heart and Arteries, by the motion of the Muscles, and action of the subtil and penetrating particles of the Air which we breath.

It is in effect the spiral and nitri­ous particles of the Air which atte­nuate and subtilize the particles of the Blood in mingling themselves in­timately together in the substance of the Lungs, which make them wave upon their centre, and which give them all their vivacity and influence which is necessary to the maintaining of their intestine motion, and conse­quently of their heat and Life.

It's certain then, that it's the Blood agitated by these means, which vivify and animate the parts, repairs the continual losses which they suf­fer, furnishes the matter of the Spi­rits, and of all the different Liquors that are subtilized in passing through a 1000 different Strainers: In one word, it's the Master spring that makes the whole Machine go.

This being so, it's not hard to conceive that it is from the actual distribution, presence, and action of the spirituous, and nourishing par­ticles of the Blood, in a part, on which entirely depend its motion and life;Cause of Mortifi­cation. so that this dispensation com­ing to cease, or be interrupted for some moments, one feels no more there, either heat, motion, or life. To convince our selves of it, we must only examine that which hap­pens every day in Syncop's, where we see that the pulsation of the Heart being hindred, and the circu­lation of the Blood stopt, all the Extremities grow cold, the Face pale, and sometimes lived, and the whole Body deprived of feeling and motion; but according as the Heart recovers [Page 254]its motion, and the Blood conveyed into all the parts, they recover their heat, motion, and life. It's there­fore evident, that the life of a part depends on the presence and motion of the Blood; and on the contrary I say, that the cause of a Gangrene and Mortification of a part is doubt­less the absence and want of these spirituous and nutritive particles in the same part. This is the Explica­tion which the Illustrious Etmuller gives of it in Tome 1. operum, pag. 587. where he says, Causae Gangren, & sphaceli in genere sunt & quae qua­cumque ratione sanguinis, & spiri­tuum vitalium distributionem inhibere valent.

It is a question whether the Ani­mal Spirits which run from the Brain through the Nerves, are not like­wise interessed in a Gangrene. I say, that the most causes which work upon the Blood for the production of a Gangrene, may in the same man­ner work upon the Animal Spirits; but in the mean time the Gangrene only depends on the alteration which happens unto the Blood. This is proved because a Gangrene is a pri­vation [Page 255]of Life, or at least a disposi­tion next to a Mortification; now the Functions of Life depend chiefly from the Blood, whereas the Ani­mal Functions depend on the Animal Spirits. The Nerves may be ob­structed, and the Animal Functions cease in a part without Mortificati­on, as is seen in Paralytics. It's true then to conclude that a Gangrene depends only on the default of the vital and spiritual particles of the Blood.

Those that will have the Animal Spi­rits to have much share in the Gan­grene, as well because a mortified part is deprived of motion and feeling, as because a great pain causeth an In­flammation, and sometimes Morti­fication, do not consider that the weight of the courser particles of the Blood, which lies in a part, presses the Nerves, and so interrupts the course of the Spirits, and the pulsation of the Artery is no more felt; for as Nature delights to glue the Arteries to the Nerves,Arteries for the most part joyn'd with Nerves. and that she makes use of the pulsation to oblige all the little Nervous Fibres to discharge the Spirits which they [Page 256]contain, so it will be always true to say, that the Gangrene succeeds great pains and inflammations, and that the privation of motion and feeling come chiefly from the Blood; since it's that which hinders by it's stay the distribution of the Spirits. I deny not that the want of Animal Spirits in Paralytics may give occasion to a Gangrene to seise the sooner on a part, as we shall see in the following Discourse.

After all I have said, it's easie to comprehend that the heat and life are precisely contain'd in the Blood, since the dissipation and absence of it's spi­rituous and nourishing particles cause the Gangrene, and that their pre­sence and exaltation entertain the natural heat.

True and only cause of a Gan­grene.I say then in general, that the cause of a Gangrene and Mortificati­on, is the dissipation & absence or con­centration of the spirituous particles of the Blood, which must vivify the part, or at least the interruption of the course of the same, and it's coa­gulation. These causes act for the most part separately, it may also happen that they act together to [Page 257]cause a Gangrene, as I shall make you observe.

Let us examine all these Causes, and first see what is this alteration of the Blood, that is deprived of its spirituous particles, from which fol­lows Gangrene and Mortification.

To give a just Idea of it, let's consider the changes that happen to Wine. All the World agrees,A Com­parison. that the good condition of Wine consists in the exaltation of its most subtil and spirituous principles, as long as these principles have the upper hand, the Wine remains in a state of gentle and natural fermentation, and con­sequently of goodness.

But if it happen by what cause soever, that they be weaken'd and dissipated, and the acid salts, or salt sulphurs take the upper-hand; then it is that the Wine grows sower, and at least sharp and very disagreeable. It happens also very often, that after the loss and dissipation of the spirits, there remains nothing in the Wine but Earth and Phlegm; it's without taste, and is nothing but a dead Mass and barren Liquor, which in Latin is call'd Vappa, Vinum pendulum, which [Page 258]is as it were the Cadaver of the Wine. Finally, it happens, that in cold Wea­ther the spirits of the Wine concentre in the midst of the Vessel which con­tains it, so that all the parts in the circumference being deprived of the spirits congeal. I say, that when the spirituous particles of the Blood are dissipated, or concentred, it receives almost the same alteration. If the acid salt, or salt sulphurs take the up­per hand, it becometh acid or rank. Willis uses the same Example when he explains the alterations that hap­pen to the Blood,In tract. de ferm. p. 68. in comparison to those that happen to Wine. Cum a longa fermentatione spiritus absumi, ac­tandum deficere incipiunt, inducitur de­fectionis status, quo vina aliique Liquo­res, ant in vappam transeunt, ant de­mum sale vel sulphure nimium exaltatis, acetosi ant rancidi fiunt, pariter & san­guis dum in vasis circulatur, juxta tri­plicem hujusmodi Diathesin considerari potest, &c.

Finally, when all the spirits are dissipated, that the Blood degene­rateth into a dead inspir'd mass, in­capable of any fermentation; and whenever the Spirits are concentred [Page 259]in great cold, they abandon or for­sake the exterior parts, which are then only irrigated with Blood de­prived of vital and spirituous par­ticles. This last state of the Blood answers to turn'd Wine, whence de­pends the mortification of a part in certain cases which I am going to propose.

Cause of Gangrene in old People.First, we observe, that old People dye very often of Gangrenes, and that that it begins by the Extremi­ties, and follows through the whole Body in spight of all Remedies that may be used. The same thing hap­pens through long abstinence, and after all sorts of too great evacua­tions.

To give an account of this Pheno­mena, you must observe, that the Blood can, no more than other Li­quors that ferment, always remain in the same condition. It's active principles are yet intangled in in­fancy, they get loose in our youth, remain in a state of exaltation dur­ing a certain age; but at last they are dissipated, and begin to abandon their subject in old age; therefore old People become by little and little [Page 260]incapable of their ordinary motions, they loose insensibly their vigour, till at last their life, in loosing their heat and spirits.

This being so, it's not hard to ex­plain why old People who dye after this manner are always troubled with Gangrenes in their last days, the rea­son is because their Blood becomes a Languid Mass, which no more con­tains any character of life, and which in effect is no more than a Cadaver of Blood; This kind of death one may call natural, because it happens not but when the heat is extinguished of it self, and by degrees. Ideoque mori simul dicuntur, & extingui. In this manner it is that a Mortification of the Blood and Spirits happen af­ter an Hectick Fever, long Fluxes, great Abstinences, too great Labour, and generally after all sorts of great Evacuations because in these occa­sions the Matter designed for the en­tertaining of natural heat, is dissi­pated, or is not enough furnished to supply the loss of it which it actually suffers.

Of the rest, though in this state of the Blood the Gangrene be almost [Page 261]universal, and need no other cause to manifest it self, yet sometimes it happens, that the slowness of the circulation gives it occasion to attack certain parts, there is a very parti­cular case of it in the 46th Chapter of the Second Book of TULPIUS his Observations. Observa­tion. Where he relates, that an old Man was reduced to such a languishing condition, and so great a weakness, that the least impression caused him to have a Gangrene, he dared not so much as sit down, nor lean on an Elbow, nor even set a Foot on the Ground, or press any of his Members, but there appeared some marks of Mortification which followed the Gangrene. This Ob­servation is rare and singular: We must confess that his Blood was migh­tily exhausted of spirits, since a slight compression only was capable to pro­duce a Gangrene in a part.

We need not search any where else for the cause of a Gangrene which happens to the Legs and other parts of Hydropics, what I have said explains it sufficiently, besides we well enough conceive that the serous Blood is deprived of spirits, that it [Page 262]moves more slowly in the Extremi­ties than any where else, and conse­quently the heat must rather be les­sen'd in these parts than in others, as I have made you observe when I spoke of the Dropsie, besides the ferosity filters in so great a quantity between the Fibres and the parts, that it may by its weight press the Vessels, and so cause a Gangrene.

Secondly, great Cold causeth of­ten Gangrene and Mortification in the Extremities, especially the Feet, Hands, Ears, and Nose, particularly in Persons obliged to march in the Snow during excessive rigours of Winters, as those which Travel in the Northern Regions.

How Cold causes a Gan­grene.To explain this Phenomena, you must only remember what I have said in the comparison of Wine, where we have seen that the spirits of Wine are concentred by the cold, and that the exterior parts finding themselves deprived of spirits, freeze. This happens to a Bottle of Wine exposed to a very cold Air: You may observe in breaking the Bottle, that the spi­rits have retired to the center, and preserved their fluidity while all the rest is congealed.

I say that the same thing happens in the Blood by the rigour of cold, and while the spirits retire to the center of the Animal, the exterior parts remain gangrenated, being only irrigated with a dead and insipid Phlegme, which congeals in the very substance of the parts.

It's easie to comprehend, that at the same time the parts feel the pinches of the cold, they retire, be­ing compress'd by the action of the Air, which first causes those quick and penetrating pains, and hinders the Blood from continuing its motion in those parts, therefore lying there still, it insensibly stops every passage, and causes an entire mortification. Hinc Interdum (saith ETTMULLER) ex frigore extrinsecus Irruente partes Gangrenosae fiunt.

So much for what regards all kinds of Gangrenes that depend on the dissipation and concentration of the spirits,Tumors, Fra­ctures, Luxati­ons, &c. may cause a Gan­grene. now I come to those that de­pend on the interruption of the course of the Blood, and its motion.

First, Tumours, Fractures, and Luxations, may cause a Gangrene in a part, by compressing too hard the [Page 264]Vessels that convey the Blood there; I confess that this kind of Gangrene is rare, because the Vessels commu­nicate themselves in so many places, and there coming so great quantity of different branches from them, that it's difficult that all the supply of Blood should be hindred in a member.

Nevertheless Fabritius Hildanus assures us,Observa­tion. that he hath seen a Man who was attack'd with a Gangrene in both Legs, and his Feet were always cold and be­num'd; so he died without a Fever, & without any other symptomes: His Body being opened, there was found a schirrous Tumour in the Region of his Reins, over the division of his Iliac Branches. This Tumor pres­sed first slightly the Vessels, and caus­ed the cold and benumming of the Legs, but as it grew, it press'd the Artery and Vein so hard, that the Blood could no more descend into the inferior parts to vivifie them. Concerning Fractures of Disloca­tions, it may happen that the head of a Bone or some pieces may com­press the Vessels so hard, as to hin­der the passage of the Blood; for the same reason Bandages,Too tite Ban­dages. &c. used [Page 265]in Fractures, and Luxations, strong and close Ligatures of the Vessels may cause a Gangrene, especially if one makes it on the great Trunks, unless the Branches which communi­cate together in several places, fur­nish the Blood that's necessary for the vivification of the parts. Ett­muller saith, Nimis firmae Ligaturae ex­ternae interdum hoc malum inducunt, in quod fit interdum si in ossium Fracturis Locus Fractus orcte nimis Ligetur.

In all these cases it's very easie to see, that the mortification depends simply on the interruption of the course of the Blood, without the concurrence of any other cause; but you will see in what follows, how the ill disposition of the Humours may augment, and even produce this kind of Gangrene.

A Gan­grene may happen by long lying on the Buttocks, &c.Secondly, a Gangrene happens often upon the Buttocks of those who have had long Sicknesses, and that are obliged to lie long on their Backs, first the Cutis begins to rise, afterwards there happens Inflamma­tion in the Flesh, which ends in Rot­teness and Gangrene. The first is caused by the sole compression of the [Page 166]Vessels in the part; but if at the same time the Patient involuntary sheds his Water and Excrements the Gangrene comes sooner, because they gall and heat the parts by their acrimony, and so increase the In­flammation, and consequently the Inflammation and Gangrene.

Great In­flamma­tions, Contusi­ons, &c. may cause a Gan­grene.In the third place, nothing's more common in the practice of Chyrur­gery, than to see Gangreens follow great Inflammations, Contusions, and even Anevrisms, when ever the Tunicle of the Artery is broke, and the Blood extravasated between the Muscles; I say, that in all these oc­casions, if the Blood be extravasated in great abundance, it must needs lie heavy on the part, and press at the same time the Blood Vessels, so that it entirely stops the passage to the new Blood, which comes to irrigate and vivifie the part. Behold this is the period of Inflammations proper to produce a Gangrene; and as there must be great abundance of Blood to compress hard the Vessels, so it happens only upon great Inflamma­tions. If I say that in great Inflam­mations the Extravasated Blood com­press [Page 267]the Vessels, it's not a simple Imagination only, but a constant Truth; since the Pulse ceases to ver­berate, at the same time the part be­gins to gangrenate, and it's red co­lour grows pale, livid, and black; which clearly demonstrate that the sanguiferous Vessels are compress'd, and the access of new Blood hin­dred.

Reper­cussive Astrin­gent Me­dicines improper­ly applied may cause a Gan­grene.In the 4th place, a Gangrene may happen upon the least Inflammation, even on Érispielas, when ever too strong Repercussive, Astringent or Emplastic Medicines are inconside­rately applied.

To conceive this well, you must observe, that the Extravasated Li­quors transpire very much, and that this Transpiration does extreamly discharge the diseased part, of the quantity of Humours which it con­tains; so while the Pores are open in Phlegmons and Erisipelases, and the most active and agitated particles of the Bile and Blood evaporate, the part always discharges it self of some of its Burthen, so not much fear of Gangrene. This is the reason why in the Southern part of America [Page 268]there never was seen a Gangrene come upon Wounds or Inflamma­tions, because the great heat of the Countrey opens the Pores of the Body; but when the Pores are closed by Astringent, Repercussive, or Em­plastic Medicines, and the transpira­tion utterly impeded in the part, the Tumour increases, the part re­tains all those particles which would have escaped through the Pores; the Extravasated Humours being in a greater quantity, proportionable to the part which contains it, compres­ses the Flesh and Vessels, and of ne­cessity causeth a Mortification.

Behold the true cause of Gangrene which comes upon Inflammations, Contusions, Anevrisms, and Erisipe­las; all these causes have been very well observed by Ettmuller, when he says, Hinc est quod vix saepius oriuntur Gangrene, & sphaceli, quam ex Inflam­mationibus male curatis, imprimis si partis Inflamatae; per Emplastica impru­denter admota, impediatur insensilis tran­spiratio, tunc sanguis extravasatus stag­nat, corrumpitur, ex toto putrescit, & par­tis Inflammate Gangrenam post se trahit. In primis Erisipelata per ungt. oleosa, [Page 269]ac muilaginosa insulsae, tractata subito serpentem inducunt Gangrenam. But these causes having produced their effect, there are that augment it, and which give even occasion that it be communicated to the nigh parts, it is the corruption of the Blood and Extravasated Humours in a simple In­flammation. When the Blood is ex­travasated, and cannot be discust, it changes into Pus; This change is not only caused by the action of the principles of the Extravasated Blood, but also by the soft influence of the Blood and Spirits which are con­tain'd in the neighbouring parts; This makes that the Pus is not al­together a strange substance, and enemy to Nature. But as I have shew'd that the access of the Blood is entirely press'd towards the Gan­gren'd parts, and the circulation very often intercepted, it so happens that the Extravasated Blood is so far from being converted into Pus, that it de­generates into a virulent Sanies, which first causeth Blisters upon the part, and then by its acrimony gnaws the Gangrened parts, and insensibly corrupts those that are sound; [Page 270]which makes the Gangrene become so angry, that it attacks even the parts that suffer no Inflammation. Of the rest, the Gangrenes which fol­low upon Inflammations attack ra­ther the soft and fungous parts, than other,Why the soft parts Gangre­nate soon­er than other. as the Gums, Lips, Vulva, and Membrum Virile, Intestine and Brain. The reason is, these parts being very soft and spongy, imbibe a a greater quantity of Humours; be­sides, the most of them have no Muscles that might squeeze the Blood, which makes it easily lie caking there.

Ulcers, Wounds, Scorbutic spots, and sharp Me­dicines, may cause a Gan­grene.Fifthly, Gangrene comes upon Ul­cers, Wounds, Scorbutic Spots, and upon the Application of sharp and corrosive Medicines, which happens two ways;

• 1. When pain, which ac­companieth all these symptoms, causes often great Inflammation, on which followeth Gangrene.
• 2. From the Actual Cauteries, from Pus and Sa­nies coming from gnawing Ulcers, from Scorbutic Spots, and from sharp and Corrosive Medicines, which cau­terise the Cutis and Vessels, so the Blood being no more sent into the parts, they lose their motion and life.

Maligni­ty may cause Gan­grene.Finally, all Authors do admit a malign and occult cause of a Gan­grene, from thence (they say) comes the Gangrene in the Plague, as Car­buncle, which sometimes in 24 hours time causes an entire mortification of a part; To the same cause they at­tribute the Gangrene which happens on Malignant Fevers, and sometimes after the Small Pox, by a depositum (or Crisis) of the Matter which the Disease makes in some part. Lastly, it's this way which they pretend to explicate the Action of Poysons and Bites of Venemous Animals, which they say will cause a Gangrene.

But (without having recourse to the Malign and Occult qualities of the Plague) are we to wonder at Carbuncles causing a Mortification in any part,Why a Carbuncle mortifies. since the Humours which produce them are in the highest de­gree of Sharpness and Corrosion; It gnaws the Flesh, and cauterises the Vessels; so it's evident the part must mortifie. The same thing may be said of the Matter of Malign Fevers, and of the Small Pox, where the Blood is loaded with sharp and malign particles, if so be that this acrimony [Page 272]cannot be overcome by Nature, or by Medicines, there is a depositum made of it in some part, where the sharp and corrosive Humours do not fail to gnaw the Flesh, cauterise the Vessels, and even to rot the very Bones, as we have seen in many Examples.

I say the same thing of Poysons that do not work but by their acri­mony, of which some are acid, and others abound with lixivial salt, but always they produce the same effect, as we daily see it happen by the ap­plication of Acids and Potential Cau­teries.

After the Explication of the Causes, we must pass to the signs and diffe­rences of a Gangrene; as for the dif­ferences it's easie to draw them from their Causes, I pass to the signs which are of more importance.

Signs of a Gan­grene from want of Spirits, &c.The signs of a Gangrene which attack old People, and which comes from the want of Spirits, are known by that they feel neither pain, nor have Inflammation; the parts fade a­way, and are (as it were) deprived of sense and motion, which makes them die insensibly.

Signs for the Drop­sie.In a Gangrene which succeeds the Dropsie, there is but a slight pain in the beginning, but afterwards the Legs inflame, and the pain aug­ments.

Signs from Cold.If it be caused from External Cold the pain is presently sharp, the part grows red, livid, and then black; at last the spirits forsake it, and mor­tification seizeth, accompanied with a shivering like that in an Ague.

Signs from Com­pression, Tumours, Luxati­on, &c.If the Gangrene be the conse­quence of some compression, as of too narrow Ligatures, Tumours, Luxation, Fractures, or of too long lying on the Back, it's known by the benumming, or by a total priva­tion of feeling and motion, accord­ing as the compression is more or less strong.

Signs from In­flamma­tion, &c.If it be caused by Inflammation, the pain and pulsation ceaseth, the part which was red groweth pale and livid, there are some little Blisters form'd upon the surface of the Skin, fill'd with salt Water like muddy Wine, the heat is extinguished, the part groweth soft and withers, so that being pressed with the Fingers the dent remains; Finally, if the Mor­tification [Page 274]be perfect, the Patient falls into great weaknesses, accompanied with a burning malignant Fever, with Vomiting, and several other symptomes, which shew, that the Mass of Blood is very much op­pressed, and Death must needs fol­low upon it.

Signs from Re­percus­sives, &c.The Gangrene which is produced by the use of Repercussives and Em­plastic Remedies, is accompanied with the same accidents.

Signs from Caustic Medi­cines.The Signs of that which comes from the use of actual Cauteries and Caustick Remedies, are almost al­ways the same as in that which pro­ceeds from too strong Compressi­ons.

Signs from Ma­lignity.As for the Gangrene which comes from any Malignity, as from the Bite of a Venemous Animal, besides the signs of mortification which ap­pear upon the part, several others manifest themselves, as Carbuncle, Fever, Vomiting, Syncope, and Phrensie.

Signs of a Spha­cel.The Signs of the Sphacel do not differ from those of the Gangrene, but Secundum Majus and Minus; A Sphacelated part is heavy, black, [Page 275]stinking, and withered; feeling is quite lost, and the Skin is easily se­parated from the subjacent Flesh, fi­nally, from being soft as it was be­fore, when it was Gangrenated, it dryeth up when it is entirely morti­fied. You must observe, that if the motion sometime remain in a spha­celated part, as in the Foot, &c. it proceeds from that the Bellies of the Muscles which are not interessed, making their contraction, the Ten­dons in the mortified part are obliged to follow their motions. I pass to the Explication of the chiefest Ac­cidents.

Cause of the Bli­sters.The Blisters that come upon the Skin, proceed from the Blood lying caking and curdling in its parts, there separating from it a sharp and cor­rosive serosity, which insinuates it self under the Skin, separates the Cuticle, and raiseth it almost like as in Scalds.

Cause of the Black­ness.The pulsation ceaseth in the part, and its colour grows pale and livid. I have shewed that the pulsation ceased by the compression of the Vessels; It's probable that the red colour disappears for want of new [Page 276]Blood, and that which lyeth caking rots in the part, giving a violent or black colour according to the degree of Corruption and Mortification.

Cause of the Pains.The pains proceed from the irri­tation and great impression which the sharp and malign serosity makes upon the Membranes, and on the Nervous Fibres which are dispersed in the parts.

The Pains cease, because the Ex­travasated Matter lies heavy upon the Nerves, as well as upon the San­guiferous Vessels, and stop entirely the passage of the Spirits; we also observe, that the pain gives soon o­ver after the pulsation. Some mo­dern Authors pretend it to be enough, that the motion of the Blood being hinder'd in a part, to abolish the sensation, and motion, without the Nerves being compress'd; to prove it, they tie the descending Aorta, and they observe the inferior parts de­prived of sense and motion; but they do not consider, that these parts be­ing no more irrigated nor stretched by the Arterial Blood, they must needs sink and dry up, and the Nerves, whose substance is very soft, [Page 277]must be pressed; from whence I con­clude, that in all kinds of Gangrene where the feeling is entirely lost, the Nerves do always suffer some com­pression.

Cause of the soft­ness.The softness of the part proceeds from the abundance of serosities that water the Fibres, but also being no more vivified by the Blood and Spi­rits, the relax, and loose entirely their spring or Elaftic Vertue.

Cause of the Pro­gress of a GangreneThe progress of the Gangrene comes sometimes from the Blood, which ceaseth to vivifie the parts, as in old People; but for the most part it comes from the Action of the acid Juices, which gnaw and successively destroy the neighbouring parts: It's doubtless this malignant Matter which causeth the Fever, Syncope, and the other Accidents which are ordinari­ly before Death. Thus having spoken of the Causes, Signs, and Accidents of the Gangrene, I come to its Prog­nostics and Cure.

A Gangrene which attacks old People, and Hydropic's,Progno­stic's. for want of Natural heat, is always mortal: In this kind of Gangrene, where the Spirits have forsaken their subject, we [Page 278]must not undertake the Operation, because the Patient would infallibly succumb under the violence of the pain.

That which possesses the soft and tender parts, especially the internal, is ve [...] dangerous, and degenerates very often into a Sphacel. It's also sooner cured in young than old, in strong Bodies than in Cachochymic.

Cure of a Gangrene from Gold.The Gangrene which is caused by Cold, and which ordinarily possesses the Extremities, may be cured, pro­vided the part be not entirely mor­tified, you bring the Patient near a moderate Fire, chafe the part, or steep it in luke-warm Water, and when the great Cold diminishes, and the Spirits begin to spread themselves upon the surface, you apply Fomen­tations & Similia. That which fol­lows great Inflammations, Tumours, Fractures, Luxations, Contusions, Anevrisms, Erisipelas, Ulcers, Scalds, Scorbutick Spots, Venomous Bites, after application of too Emplastic Medicines, Caustics and Actual Cauteries, and generally upon all strong Compression, may be cured in the beginning; which makes us [Page 279]consider these kinds of Gangrene in two different states, as that of their Birth, and that of their Perfection. In the first, good Remedies capable of smothering and stopping this Dis­ease, as deep Scarifications, which disengage not only the part, but al­so give occasion for the Medicines to penetrate and produce a more sensible effect. If in spight of all this care the Gangrene should increase, and incroach on the neighbouring parts, lay aside the use of Medicines, and proceed to Amputation of the Mem­ber, that the Mortification may not be communicated to the whole Body.

CHAP. XXXVI. Of Amputation.

YOU must observe first of all, that though a part be Mortified, and Amputation the only help to save a Man's Life, yet you must not always declare for the Operation; for Example,When the Operati­on is not to be at­tempted. when the Mortifica­tion possesses the superior part of the Arm, or Thigh; it would be a pro­faning it to undertake it, (being too near parts so necessary for Life) with­out causing the ruine of the whole Subject. If it only possess the Ex­tremities, and an acute Fever, Syn­cope and Vomiting which are Mor­tal Symptoms) [...] accompany it, and the natural disposition of the Hu­mours be entirely perverted and de­praved, the Operation would prove very dangerous and hazardous

Every one knows that this Opera­tion is practised in great shatterings of the Bones, in old Ulcers and Fi­stula's of the Joynts; but it's first ne­cessary to examine the Nature of the [Page 281]Wound; For Example, if the Bone be quite broke to pieces, if the Splints be engaged, and (as it were) forced down into the Flesh, or among the Tendons; if they prick some Nerves or Sanguiferous Vessels, so that they cannot be restor'd to their natural position, it would be necessary to try the Operation; but if the acci­dent be not too great, and the pieces can be brought level again with the Bone, be no way alter'd, nor have caused any Inflammation, or pain; one might hope for its cure by Me­dicines, unless some Joynt be con­cerned. In a word, I say that all compound Wounds are of difficult cure, how inconsiderable soever the complication be, especially there be­ing any indisposition in the subject. In this occasion the Pain and Inflam­mation, the two Accidents most to be feared, particularly when they continue, and produce some more troublesome, and when the Acci­dents are pressing, it's dangerous to delay, and very often the Operation it self is not able to overcome them.

As for old Rottenness and Fistula's you must observe the same Circum­stances, and have regard unto three things, to the Nature and Cause of the Disease, to the Part affected, and to the Supervening Symptomes.

To judge whether the Fistula's, &c. are curable, and may be over­come by Medicines, it's necessary to examine whether they have been of long continuance, the cause that pro­duced them, and that which foments them.

If the Cause of the Rottenness and Fistula's proceed from some Wound or Contusion, and the Patient have not been long troubled with it, if the Joynt be no way alter'd, and the Humours which foment them be not malign, Medicines may terminate the Cure. But if the Cause proceed from Scrophulous Humours, Critical Imposthumations, or from the gene­ral perversion of the Humours, if they be old, settled in the Joynts; and finally, if the Rottenness, Callo­sity, Pain, and Inflammation be con­siderable; In a word, if the part be no longer able to perform it's functi­ons, you must have recourse to the [Page 283]Operation, provided the strength of the Patient give leave; but before you put it in practice, you must pu­rifie the Mass of Blood and Humours by general Remedies, as Diaphore­tic's, and Cardiac's.

I will not give you here an ac­count of the Medicines which are employed as well Internally as Ex­ternally, to hinder the disorder of the Gangrene, being obliged to speak of them in a Treatise of Wounds, and as every kind of Gangrene re­quires particular and different Medi­cines, so it's the part of a prudent Chyrurgeon and Physician to order and use them according to their Idea's and Understandings.

Several Circum­stances to be ob­served.Before you go about the OPE­RATION, you must observe several Circumstances. If it be the Arm you cut off, you must cut off as little of it as possible, because the little that remains serves in a manner to the functions of Life: If it be the Leg, though only the Foot should be con­cern'd, you must Amputate 3 Fin­gers below the Knee, just under the Aponevroses which cover the Rotula, because of the long suppurations [Page 284]which rot the Tendons, and other accidents that may happen; and to put on an Artificial one more easily.

Never Ampu­tate in the Joynt.You must never amputate in the Joynts, unless it be in the Fingers or Toes, which we are obliged to take off. If it be the Thigh, am­putate as little as you can, because the more you cut the greater is the Wound, suppuration longer, and the cure more difficult, and conse­quently the Patient's strength dimi­nishes, and grows more weak.

How to Ampu­tate.Having chosen a proper place, we perform the Operation thus. If it be the Leg, you place the Patient on the edge of a Bed, lying half back­wards, one sustains him behind, a Servant clasps his two Hands about the inferior part of the Thigh, and draws the Skin upwards, another holds the Leg, whilst the Surgeon puts on the Ham a Compress of se­veral folds, of a fitting bigness, with another pretty large Compress, which encompasses the whole part, upon which you place a Ligature, which must be streightned with the Tor­niket; but being it must be tied very hard, sufficient to compress the [Page 285]great Vessels, you may place a Past-board under the Ligature, that the Patient may feel less pain, and for hindring the Skin from wrinkling; Then you make two other Ligatures, one over, and the other below; the first keeps the Skin which you raise upward, and the other fastens the Flesh; Then the Surgeon places himself between the Patients Legs, and with a crooked Knife which he holds in his Right Hand,How to cut the Flesh. he makes an Incision about the Member even to the Bone, and with the Back of the Knife separates the Periostium, and cuts at the same time the Flesh and Membranes between the Bones, lest you rend them with the Saw, and so cause new accidents; but be­fore you saw the Bones, you take a Fillet of Linnen which you split in two parts, and you make use of it to raise the Flesh, and to give liberty to saw the Bone as near to the Flesh as possible; for seeing it wastes and consumes in suppuration, if this pre­caution were not taken, there would stick out an end of the Bone deprived of Skin and Flesh, which would serve for nothing but to incommode the Patient.

How to saw the Bone.This being done, you take the Saw, which you carry obliquely over the Tibia, which also serves for a support to saw the Fibula, which is the weaket; which obliges us to saw it before the Tibia, to avoid its crack­ing or shivering.

You must observe, that in the time of sawing, the Servant must bend the Leg a little inward, that the Saw may pass more easily. The two Bones being sawed off, you take off the Li­gature above, which held the Skin fast, you loose the Torniket; to find out the Artery, you take hold of it with the Crow's Bill,How to tye the Artery. or Pincers with a Ring, then you take a crooked Needle arm'd with Wax'd Thread, which you pass twice into the Flesh under the Artery, that it may be en­gaged in the Loop of the Ligature, which you tie very hard; you make a knot over the Artery, upon the knot you apply a little compress, which you fasten with two other knots, you again loose the Torniket; If the Blood should run out with any violence from any other Artery, you make another Ligature as the first.

Some to stop the Blood use an Actual Cautery, others a Button of Vitriol, which they wrap up in some Cotton; some tye the Artery with­out passing the Ligature through the Flesh: But I think the true and surest Method to be as I have describ'd. The Ligature being made, you take away the Turnstick from off the Stump,Where to use the Suitches, how to dress Stump. and endeavour to cover it again with the Cutis; If it be Thigh or Arm, it's not enough to cover the Stump again with the Cutis, but you must keep if so by the help of four Stitches, which must not be practised at the Leg, or below the Elbow; be­cause the Knee or Elbow hinder it from rising too high, you apply little compresses upon the Vessels, and a dry one on the Bone, or soaked in Spirit of Wine to correct its altera­tion, then several other Boulsters arm'd with Astringent Powders, over that a little Two spread with the same Powders, a Defensative and Compress like a Maltha Cross, two Longitudinal Compresses, and a Cir­cular one, sustain'd by the Circular Bandage and Capling; some days after you use only the Circular one, [Page 288]you need not load the part with too many Compresses,A Hogs Bladder of no great use. nor apply the Hogs Bladder, neither tye the Ban­dage too hard; for besides that all these things excite only Obstructi­ons and Inflammations, & if by chance the Ligatures should fail, the Patient would infallibly perish unawares, be­cause the Bladder could retain all the Blood that should run out. You must take care in pulling off the Dressings, not to handle them with too much violence, lest you pull also off the Ligature. You must take care after suppuration to press the Stump a little by means of the Compress, to hinder the generation of fungeous and superfluous Flesh, which ordina­rily happens after long Suppurati­ons.

Caution to be used in apply­ing the Vitreol Button. Those that use the Vitriol Button must precisely apply it to the mouths of the Vessels, and take care it doth not fall in applying the Bolsters. Nevertheless though we have disap­proved its use for several Reasons; yet those that will make use of it ought to lift the Stump up a little, and hold the Hand upon it for 3 or 4 hours, until the Vitriol hath begun to produce its effect.

In happens sometimes, that after the Operation the part suffers some Convulsive Motions,Cause of after Convul­sions. occasioned by the Spirits being irritated by sharp, corrosive, or Vitriolic Matters, or by the trouble of the Spirits themselves in the part. For if we consider that the Brain actually prepares a certain quantity of Spirits, which run through the Nerves, to serve the Functions of the whole Body, we shall agree, that those which are designed for the motions and sensation of that part which is no more existent, but separated from the others, must needs run back; It's perhaps this unlucky reflux which excites these irregular Convulsions, and the involuntary Contractions pull along with them the Arteries, and so gives occasion to the Ligature to break, and the part to bleed, which often causeth Death. Therefore in these Occa­sions a Chyrurgeon must not stand searching for the Artery, he must only lay upon it the Vitriolic Button, with Bolst [...] [...]oaked in some Styp­tic Liquor. These are the measures which you must take in such Occa­sions.

CHAP. XXXVII. Of Paronychia.

PARONYCHIA is a very pain­ful Tumour which possesseth the Fingers ends, caused by the altera­tion and effervescency of the Bilious and Sulphureous Particles of the Blood.

Two kinds of Paro­nychia.They ordinarily make two kinds of it; in the one the Matter lies be­tween the Periostium and the Bone, accompanied with a burning heat, acute pain, and deep pulsation, great Tention, and burning Fever; The other is only in the Flesh, with less heat, and pain, lighter pulsation, less Tention, and hardly any Fever at all.

Cause of the Heat and Pain.The heat and pain come from the strong ebullition of the Blood, and many irritations whi [...] [...]he sulphure­ous particles (that [...]elt, and are [...]rn'd into Sanies) excite at the Fibres of the Periostium.

Cause of the Ten­tion.The Tention proceeds only from the fermentation of the Humours, it's easie to comprehend that when a Liquor boils, it extends it self more in length and breadth than when it is at rest, and must consequently di­late the Vessels (in a great manner) that contain it.

Cause of the Pul­sation.The Pulsation is nothing else but a more exquisite and lively feeling that we have of the Arteries beating in the inflamed part, caused by a great Tention and Effervescency of the Blood.

Cause of the Fe­ver.The Fever comes from the mutual agitation of the different particles of the Blood, that fight against one ano­ther with great strength, and tear one another in a thousand little par­ticles of a different bigness and figure, which being moved in the mass of Blood excites the Fever, but after a long struggle the Pus is made, the Vessels burst, the Matter Extravasates, the Tumour grows softer, the Fever and all other symptomes diminish, then we give the Pus Issue, by Inci­sion,Where to make the Incision. which we make at the side of the Finger to avoid the Tendon, we then use those Medicines ordinarily used for other Ulcers.

I will no longer insist upon the Pa­ronychia, though it would furnish us with Matter for a long Discourse, and seeing most Authors have given their Opinion of it, any one may be Instructed by them.

CHAP. XXXVIII. Of the Use of Cupping-Glasses.

MOST Practitioners of Phy­sick are wont rather to ap­prove the use of Cupping-Glasses and Leeches, than condemn it, be it, that they either found themselves upon that pretended Attraction of the An­cients,Cupping-Glasses of very little use. or that they think to discharge sooner a part loaden with the weight of some strange Matter: It's true, they use them but with little success; besides this Attraction is just a Chi­mera, and is the most cruel and te­merarious practice that can be ima­gined; What appearance is there to scarrifie the Back, to dissipate Inflam­mation of the Eyes? To slash the Loyns to hinder the progress of ma­lign [Page 293]Fevers;No such thing as Attracti­on. to cut the Skin and Flesh in 20 different places, to draw one or two Ounces of Blood? I do not believe that those who have an Idea of the Circulation of the Blood, can shew me by Experience, or any other way, that the division of some Cupillary Vessels are capable of curing the least Cutaneous affect. Never­theless there are some that do au­thorize this practice, maintain, that the Scarifications do determine the Blood and Spirits to repair in abun­dance to the scarified parts, and that in moving the Humours after this manner, the afflicted part is disen­gaged, and the Inflammation les­sen'd.

It's to be wished for the Partisans of this practice, that the Inflamma­tion would favour their Opinion. For we cannot believe that the Blood and Spirits running into a part in a greater quantity than the used to do, without causing some Inflamma­tion, which is not observed here; be­sides,Inflam­mation caused only by the interrup­tion of the Blood. that the Inflammation comes not, but because the motion of the Blood is intercepted by the divulsi­ons of the Vessels, as it happens in [Page 294]all new Wounds, and not at all by a determination occasion'd by the Pains.

Lastly, all the Vertues which are attributed to Cupping-Glasses, shall not hinder me from disapproving their use; for I say, that they are not only useless in many Diseases where they are employed, but also in Venereal Sores, and Bites of Ve­nomous Animals, since it's certain, that the Poyson of these Animals, which consists in a strange acid, ma­nifests it self in a moment to the Brain, in spight of the influence of the Spirits, and that the Mass of Blood is presently oppress'd with it, by the Laws of Circulation; from whence I conclude, that once Bleed­ing, or the least Sudorific in what Disease soever, will always do more good than all the Cupping-Glasses you can apply.

Leeches very of­ten the cause of Fistula's.You must observe, that in the Hemmorhoides, Emollient and Discus­sing Remedies are to be preferr'd before Leeches, which are very often the cause of Imposthumes, and Fistu­la's in the Anus, as I have shewed you in the Treatise of Fistula's.

Where and how to make an Issue by Cau­stic.I also say by the bye, that Cau­stic's are not applied upon Nervous parts, nor upon the great Vessels, but always between the Muscles. You first rub the part with a warm Cloth, to open the Pores, and to make the part in a manner insensible; you put a Plaister on it with a hole in the middle, to put the Caustic in, which you cover with a Compress, and with a little Fillet.

CHAP. I. Of Incised or Contused Wounds of the Flesh.

TO finish this Treatise I thought fit to relate the most Impor­tant Observations which re­gard the Cure of Wounds, and to clear the stiffest difficulties which puzle most Chyrurgeons, in the Me­thod of discussing them well, with­out which we cannot obtain our wish'd for end.

Those that hitherto have treated of them, have been satisfied to hold long Discourses about their several Kinds, Differences, and Prognostics, but seeing these sorts of useless Dis­courses serve only to tire the memo­ry of those which seek to be In­structed, I will not repeat them; I begin first with the most simple and known Symptomes.

To stop the Hemor­rhage in Wounds.Being the Hemorrhage is the first and most dangerous Symptome of Wounds, it's that which the Surgeon must quickly correct, in closing the vessels from whence the Blood flows. For if you stop them the Blood runs no more, that is to say, you must put into their Apertures some Medi­cines which hinders the effusion of the Liquors they contain, or in tying or compressing them. These two last Methods are the surest, because one may order them as one please, so that the Intention for which we make the Ligature, or introduce Lint into a new Wound, is to hinder the flux of Blood, in pressing the Lint a little to oblige the sides of the Vessels to approach, and resist the Impulsion of the Blood, yet so that the Compres­sion [Page 298]excite not Inflammation. A Wound having been so dressed, it's of importance to prevent the Inflam­mation and Pain, which are the two accidents which always accompany it.

Cause of Inflam­mation.The Inflammation or Tumour pro­ceeds from the Circulation in the part being impeded, by the division of the Vessels, the Grumous cloded Blood, and the Dressings. These strange Bodies are as so many Sluces which oppose the course of the Blood, obliging it to stop and excite In­flammation.

Cause of Pulsative pain.I conceive two sorts of Pain. The first is a Pulsative pain, which de­pends on the Arteries, that creep a­bout the Nerves, which at that time are so extended, that they strike the Nerves more rudely than they used to do, and make them suffer so great distentions, that they break, and it's this plurality of divisions which cause the Pain.

Cause of the quick and burn­ing pain.The second is a quick and burning Pain, caused by the suppression of the course of the Blood, which by the motion and frequent shocks of its most active principles, bursts the [Page 299]Vessels, and extravasateth between the porosites of the Flesh, where it's ra­rified by the great quantity of con­centred Spirits, which penetrate the most insensible Porosities. Then doth the Blood by its irregular action shake, and violently prick the little Nervous Fillaments, from whence proceeds this second kind of burning pain.

2. To pre­vent pain.We commonly prevent these two Accidents, by repressing the motions of the Blood, which comes to the part with too great precipitation, by Repercussives and gentle Astringents. Bandages are of the first rank, which we use very successfully in binding the Wound up gently, as also the neighbouring parts; whereas too tite a compression would augment the Inflammation. It's for this end we readily employ Defensatives, as we call them, because they are compound­ed of a Desiccative Matter, which in­sensibly shuts up the porosities of the Vessels, as Terra Sigillata & Bole mixt with the White of an Egg, or com­mon Water.

You must observe never to leave them longer on then 24 hours,Caution. for Reasons which we shall alledge here­after. You must at the same time sweeten the acrimony of the Blood, and empty the Vessels by Phleboto­my, Clysters, and a good Diet.

A thin Diet ex­ceeding good in Wounds.If the patient would be prudent in his way of living, and use only a thin spare Diet, he would suffer much less pain, and his cure would be quicker, because Salt Meat is capable of thickning the Blood, and making it fit for fermentation, whereas sweet Liquids, by their insipidness dissolve and charge themselves with the salt, and precipitate it by Urine; after this manner the intemperies of the Blood is corrected, and the affected part relieved.

Benefit of Clysters.Clysters are also of great use, be­cause they hinder the Excrements from heating, and boiling back again in the Intestines, they dilate the Mat­ter, moderate the heat of all the Viscera, and contribute much to the cure of Wounds.

Repercus­sives used only in the first Dres­sing.You must observe, that at the same time Repercussives retain the most sub­til and agitated salt particles of the [Page 301]Blood, they grow sowr, gnaw the Vessels, and excite a fermentation, upon which a Fever soon follows; They are therefore only used in the first Dressing, and prefer Discutients which open the Pores, and causes the volatile salts to perspire, and so empty the part. It's easie to see, if one continues the use of Repercus­sives, the salts endeavouring to escape, fail not to excite Inflammation, and to corrupt the nourishing Juice of the parts, in disuniting the principles of the Blood, which depend one on another, & which by the frequent en­counter, and shock of their particles, change figure; from which depends the generation of a new Matter, and all the changes which happen.Discuti­ents and Suppura­tions must work to­gether.If in such an occasion Discutients which causes perspiration, and Digestives, which excites a quick suppuration, should not work together to disen­gage the part, it would tumifie so much as to fall into Gangrene. Ca­taplasms, which have Oyls and Fats in their composition, have almost the same effect as Repercussatives, for which Reason good Practitioners dis­approve their use.

We observe, that in great Wounds Discutients excite often a fermentati­on which increases the Inflammation: In that Case, a Cataplasm made with Crums of Bread, Milk, the Yolk of an Egg, Mallow Roots, &c. is very proper. We ordinarily blame those who let the Pus lie too long in the Wound; be­cause it always gets some malignity, & corrodes the neighbouring Vessels, which presently produces Inflammati­on & Putrefaction; or else the Veins absorb it, & carry it to the Heart, from whence it diffuseth it self into the whole Mass of Blood, and causes the Fever; and according to the diffe­rent alterations which it receives in passing through the parts, it obstructs the Liver, Lungs, or some other part, so causes an Imposthume there, as we have observed in Wounds of the Head. This demonstrates to us, that we ought to dry up all the Matter that is in the Wounds, and press the Dossels into the least corner, that the Matter may not lurk there. It's so true, that the Mass of Blood takes up the purulent Matter in the time of its flay there,Matter often seen mixt with the Blood. that whenever you Bleed the Patient, you often find some Pus mixt with his Blood.

How to consume the Callo­sity of Wounds.If the Lips of the Wound grow callous, you must betake your self to general Remedies, which sweetens the acrimony of the Blood, or To­pics which digest and ripen the Mat­ter, as Emplas. Andreas e cruce, which makes the edges of the Wound ten­der, also Digestives of Turpentine, Spirit. Vini, Ol. ovor. & Pul. Aristolo­chia. If all this be not enough to waste the Callosity, you slightly scar­rifie the Lips of the Wound, to give way to the Remedies to penetrate and excite suppuration.

If the part disengages it self by a copious suppuration, you prefer Compresses soaked in warm Wine before Cataplasms, because it fortifies the part.

Always after long Suppura­tions fun­gous Flesh grows.It's observed, that after long sup­purations, there always grows proud Flesh, which is sometimes taken a­way by compressing the Wound a little; if this pressure be not enough, we use Pul. Sabinae mixt with Hony, or pass over it the Coustic Stone, or use Pul. Alum. Vet. after it's consumed, we stop its generation with the Aq. Phagodonica, which dryeth and shuts up the Extremities of the Vessels, [Page 304]which had been before relaxed by the Suppuratives, which had given room to the nourishing Juice by its overabundance to beget this fungous Flesh.

The Method is often changed ac­cording to the disposition of the Wounded Subjects; for Example, elderly People, or those that are lean and spare, have ordinarily their parts soft and loose, because a part of their heat is extinguished; in this case the Phagedenic Water would be hurtful, because in shutting the Pores too much, and not permitting their little heat to open them, the Wound would entirely dry up, Detersive and Trau­matic Medicines ordinarily supply its default, because there contain alka­line particles; which destroy the acid of the Blood by insensibly open­ing the little mouths of the Vessels, and charge themselves with the Sup­purative particles, which being unit­ed with them stick at their Extremi­ties, to regenerate new Flesh; such is the Spirit or Decoct. of these Vul­nerary Plants,Some choice Traumatic Plants. as Rad. Aristoloc. O. & Long. Fol. Vincae Pervinc. Scord. Ab­sinth. Fol. & Rad. Angelic. Consolid [Page 305]Pyrolae, Scrophulariae, Sanicula, Per­sicaria, and may others. These Symples are charg'd with alkaline particles, which absorb the predo­minant acid, hinders the rise of the Ever, and makes the Wound of a Vermilion hue.

We observe according to the de­gree of Corruption, that when the Suppurative particles cannot accom­modate themselves to the Extremi­ties of the Vessels without the help of some medium, we mix with the Traumatic Decoctions some things that have a kind of unctiosity in them, as Mel Rosat. which is admi­rable, especially when the Pus is thin and fluid, whereas if it be thick we lessen its quantity. If it be black and serous, it's a sign that it is in the last degree of corruption. As in this al­teration of the Blood where Trau­matics cannot master the Acids, we use successfully a Spirit drawn from brown Sugar,An Ex­traordi­nary Spi­rit for Wounds. Vitriol Mart. & Hep. Antim. which resists all sorts of Cor­ruptions.

This Spirit is charged with Balsa­mic, Styptic, and Alkaline sulphu­reous salt particles: The Balsamie [Page 306]particles supple the Vessels by their unctiosity, the Styptic fortifie them by their Astringency, and the Al­kalist salts blunt and master the sharp­est Acids by their porosity. I think this method of dressing is to be preferr'd before that where they use greasy Unguents, Plaisters, and Balms without intermission.

Signs of good Pus. That the Pus be right, it must be of a moderate consistence, white and without any ill smell. It often happens, that when we intend to de­stroy its acidity, there riseth a soft fungous Flesh, which depends on the great fermentation of the Acids and Alkalies, and when that fermentation ceases, that faint Flesh is dissipated only by compression. Most Practi­tioners, without any reflection, pre­sently use burnt Alom, and if it work not fast enough, they use red preci­pitate, and if that performs no more than the other, they make a mixture of them, which may well be call'd the Diabolical Corrosive; it increas­eth the Pain, and renews the Inflam­mation; But to avoid the Impression of such a strong Corrosive, you take the Traumatic Decoction, in which [Page 307]you dissolve a Drachm or two of Calcin'd Vitriol, so you consume in­sensibly the Flesh.

It's observed, that the Flesh often grows hard, especially when the part is too much loaded, or the Ban­dage too strait, the motion of the Juices being intercepted, which must be avoided in all sorts of Wounds; If the Flesh be red, and granulate well, you must not press it, you introduce only into the Wound a pledgit of Lint wet in warm Wine or Brandy.

You must never wash Wounds, it's enough to dry them with Lint; If you are obliged to siringe them,How to Siringe Wounds. you must do it discreetly, because the In­jection melts and dissolves the Flesh, so that instead of breeding good, it produces Fungous; in this case Lint only soaked in warm Wine sufficeth, because it cleanses the Wound in drinking up the Impurities it finds there, unless there be some Sinuses, which cannot be opened by reason of the Vessels, Tendons, or thick­ness of the substance which we must be obliged to offend in making the Incision; then we use Injections when we cannot introduce Lint in the bot­tom of the Sinuses.

We always observe in Wounds certain white and hard places, which are nothing else but some broken Lymphatic Vessels, and which most Practitioners take for the beginning of a Cicatrix; in that case Lime­water is useful to dry up the Extre­mity of the Vessels, and dissipate the Glutinous particles of the Lympha, which produces some Fungus's to grow over the Vessels.

It's very important to distinguish this white mark from the extremity of the cut Nerve, for if one should put on a Nerve any corrosive Medi­cine, it would excite an insuppor­table pain, which it doth not here; besides Experience Authorises it, as often as we carry off a Gland, and Lymphatic Vessel of a Veneral Bu­bo; there appears next morning a round and hard point, which cannot be consumed without Pul. Vitreol. Rub. all other as Precep. and Allom burnt, &c. work in vain. But that which is most surprising, is, that this Corrosive Powder which in 1000 oc­casions is insupportable, is not felt at all in this.

You must observe, that if some Limphatic Vessel open in the bot­tom of a Wound, and spils the Lym­pha there, it fails not to turn Fistu­lous; this for the most part happens unforeseen; in which case to cure the Fistula, you must open even to the Gland if possible, to destroy it, and drain the source of it. If you fear you should not succeed this way, you must hinder the Vessel from shedding the Lympha into the bot­tom of the Wound by drying up its extremity, and procure the genera­tion of Flesh as fast as you can.

If a Wound be accompanied with contusion, you must use the strongest Discutients, as Spirit. Vini alone, or Aromatised, or a Lixivium, which shall be described in the Chapter of Wounds made with Fire-Arms.

If the Matter discuss not, and that it increases, you must disingage the parts by Scarification, and use Medi­cines which awaken the particles of the Blood that are at rest; and force them out by perspiration, or to re­enter again in commerce with the Liquors. This is the method which you must follow in great Inflammati­ons [Page 310]where the Gangrene is apt to succeed.

The Medicines are the Decoction of the chiefest Vulneraries which we have recommended afore; The Tinctures of Aloes, Olibanum Myrrh made with the Spirit of Wine, all Me­dicines where the preparations of Mercury enter, Urine, Sea Water, Cataplasms made with Meal of Lu­pins, Beans and Lentiles, Tops of Wormwood, and Scordium boiled in Oximel Simp. These are the chiefest Remedies which are to be employed in deep Scarifications; some destroy and blunt the Acids, some sweeten and correct the Acri­mony of the Lixivial salts, others strengthen the part, and all together contribute to retain the spirituous par­ticles which are ready to escape, or to disengage them when concentred, and produce a fermentation which separates the Morbid Leavens, and restores the heat and spirits again into the part.

If a great flux of Blood follow up­on the Wound, or if any conside­rable Vessel be opened, you must make the Ligature if the place per­mit, [Page 311]or use the Vitriolic Button, or some Styptic Water, as that in Mr. Le­mery's Chymistry, and some drops of Spirit of Turpentine.

When to dilate the Wound.If the Orifice of the Wound per­mit not the entry of your Dossels, you must dilate it, avoiding the great Vessels and Tendons. This is the surest and most important practice to succeed in all Wounds, where one cannot apply Boulsters, because in discovering the bottom of the Wound you have the advantage to use Boul­sters, and reject the use of Tents, which are only Beneficial in deep Wounds of the Thorax and Belly; you may also better wipe the lesser corners of the Wound, fill it with Dossels, and hinder the Matter from cakeing or lodging it self in any cor­ner, and to hinder the formation of any Sinus. I have made you observe, that many Compresses, and too nar­row Bandages, are kinds of Ligature which stop the course of the Blood, and which increase the fluxion, and all other accidents.

A Wound ought to be dressed as soon as possible, to secure it from the Appulse of the Air, and free the [Page 312] It's of great Be­nefit to Cleanse the Cir­cumfe­rence of Wounds.Patient from some Pain. You must also take care to cleanse well its Circumference, which is a very im­portant Circumstance, because the Cataplasms and Emplasters which are applied upon it, stick to the Skin, and form a kind of Scab which hin­ders the effect of the Remedies, and retain those particles of the Blood which would transpire, whereas if you free the Skin from this Scabbard, the Remedies presently enter through the Pores, as soon as they feel the heat, they favour the transpiration, the part empties it self, the accidents diminish, and the Wound unites more easily. You must observe, that Em­plasters compounded of Fats, Gums, and Powders, serve only to retain the Dressings, and to oppose the Ex­altation of the Juices. For which reason good Practitioners condemn them.

In the time when the Wound be­gins to cicatrise, and the Flesh grow­eth unequally, we let it increase till all Inequalities are fill'd; then we dry them with Lime-water,How to Cicatrise Wounds. or some other Dissicative Medicine, to cause an even Cicatrice. If the Flesh [Page 313]arise too high, you pass gently the Infernal Stone over it.

To this Method of dressing a Wound, I will yet add, that the si­tuation must favour the Circulation of the Humours, and the running out of the Matter. These are the chiefest Circumstances which must be observed in dressing Wounds in the Fleshy parts, where the Inflammati­on, Aperture of any great Vessel, great loss of substance, and the Con­tusion doth not permit us to practice the Sutures.

CHAP. II. Of Punctured Wounds, or those made with a small and sharp­pointed Instrument.

WOunds that pass through are not so dangerous as those which have but one Aperture; they are sometimes cured by the help of Bandage applied outwardly with some Boulsters soaked in Spirit of Wine.

Signs when to dilate the Wound.If one be pain'd, and the part inflamed, it's an evident sign that there are some Obstructions, Extra­neous Bodies, which hinder the uni­tion. These two Accidents do also signifie the necessity that there is to dilate it, for to carry Remedies to the part, and give a greater vent to the Matter, we most commonly introduce two Tents of Lint of a length and thickness proportionable to the Orifices, we fasten Threads to them, and dip them in some Dige­stive made of Ol. Ovor. Spirit Vini, [Page 315]and Turpentine, which we alter ac­cording to the different degrees of Inflammation; if the Suppuration be plentiful, the Spirit of Wine must predominate; if suppressed by the Inflammation, we must correct the Spirit of Wine, by putting to it more Turpentine.

If the Pus be good, and the most intimate parts re-unite themselves, you must continue this Method; but if it be black, and Inflammation succeed, Phlebotomy, reiterated Cly­sters, and cooling and opening Fi­sans must not be neglected, we cor­rect the Digestives with Ol. Rosar. Traumatic Injections with Brandy in this occasion are admirable.

If notwithstanding these precau­tions the Inflammation incroaches upon the neighbouring parts, with putrefaction, you must dilate it suf­ficiently to discover the place where the Matter lodges; by this means you discharge the part, and dress all the corners where the Matter for­merly was nestling, and so prevent Gangrene and Mortification.

Where prepared Sponge is better to dilate with than In­cision.Concerning the Dilatation of Wounds, there be some who pre­tend that the prepared Sponge may supply the want of Incision; I own, that, in places where much dilating is not wanting, and where the Ci­catrices would deform, as in the Face; and am so far from condemn­ing the use of it, that I say it's very necessary; but in all other Occasions the Incision is to be prefer'd.

Though a Wound goes not through and through, yet if the Probe enters almost through the part, you must without delay make an Incision on the opposite side.

The Symp­tomes which commonly attend Punctur'd Wounds.The most frequent Symptomes that happen in these kinds of Wounds, are Fever and Looseness, upon which sometimes follows Dysentery.

The Fever excites Inflammation, and retards Suppuration, that the part becomes so tumified, that a Gangrene often follows it. It's known that the different dgrees of the Fever rule those of the Inflam­mation, as these do them of the Gangrene. Bleeding, Clysters, Sweet and Liquid Food, Emollient and Dis­cutient Cataplasms made of the four [Page 317]Meals, Honey, and the Emollient Herbs boil'd in Wine, as Fol. Malve, Altheae, Senessionis, Violar. Rarietariae, Candilariae, Chamomillae, Meliot. &c. All these Medicines are very Effica­cious here.

You must observe to let the Cata­plasms be very moist lest they dry up; and so instead of Humecting and Mollifying the Fibres, they obstruct the Pores as Astringents, and hinder Transpiration.

If in spight of all this care the In­flammation goes not off, you relieve the part by some slight Scarificati­ons; if they be not enough, you make others deeper, that the Medi­cines may have room to work.

If the Wound be superficial, you must dilate it; but if it penetrate even to the most intimate parts, I mean near the great Vessels or Bones, you must keep to Scarifications, and Injections made of Traumatic Plants, Mel. Rosar. and Spirit of Wine, be­cause you would be apt to ruine the whole part by the Incision, which must afterwards be cut off.

It often happens, that the Gan­grene comes on the sides of these kinds of Wounds, where the Ob­struction is always most considerable, in which case your Pleagets must be well charg'd with Digestives:

If the Inflammation goes not off either by Suppuration or Transpira­tion, and the red colour of the Skin changes not, you must use strong Ma­turative Cataplasms of White Lilly Roots, Sorrel, Leaven, and the common Digestive, provided the Inflammation communicates it self not to the adjacent parts.

Scarifications are not to be used but when the part is extreamly stretched, and the red colour changed into a livid, and when little Blisters arise which signifies a beginning Mor­tification, and shews that the fer­ment of the Gangrene is very acid and malignant; you must not stay till these little Blisters increase, but as soon as you see that the Wound doth not suppurate, and the Skin changes colour, you ought to Sca­rifie, and lay Compresses upon the neighbouring parts, soak'd in warm Wine and Brandy.

The Fever is sometimes extin­guished by Scarification, because the Agitated Matter of the Acid ferment hath room to escape; so the Inflammation is diminished, Sup­puration procured, and the progress of Putrefaction stopped.

If the Lips of the Wound be of a Vermilion colour, it's a token that the salt particles prick the Mem­branes, and increase the Fluxion; it excites the Fever a-new for some time, and the edges of the Wound grow white and dry. This change proceeds from the salt Juices, which by their too great motion separate themselves from the sulphurous ones, so that they irrigate the Fibres, and cause a new Obstruction, which af­terwards makes the Flesh foggy and white.

We often observe, that though the Wound be often ready to Cica­trise, yet if the Fever arises a-new, it grows bigger and more dangerous than it was before, because the In­flammation makes a greater progress, in this case you touch the new form'd Skin with Aq. Calcis, in which some Mercurius Sublimat. has been dissolved; [Page 320]but without using any remedy you may cut it off, for the ferment of that Membrane infects the neigh­bouring parts. Balsam of Sulphur is very good in this occasion, espe­cially in small Putrefactions.

Flux a dange­rous Symp­tome.If a Flux come upon a Flesh Wound, it's a very dangerous symp­tome, because it only happens when the salt particles have left the part, and enter into the Mass of Liquors. Now as the Volatil salts maintain the motion of the Blood and other Humours, and have a vertue of dis­solving and making them fluid, we are to search no where else the cause of this Symptome. This Flux hin­ders Suppuration, and weakens the Sick more than all other accidents together, because of the great dissi­pation of Spirits that is made by the Stools. We also observe, that the Wound dries, shrivels, and becomes as it were mortified, according as the Spirits abandon it; and the stronger the Flux is, the more the Inflammation lessens, the Flesh dries up, and the part becomes more faint, adust and putrid. You must foment it with Aromatic Wines, and hinder [Page 321]the disunion of the salts by the help of Balsam of Sulphur; but from the moment that the Spirits exalt themselves towards the surface, the motion of the Blood slackens, the Flux ceaseth, and the Wound which before was inanimate as it were, re­vives again.

This Flux must be stopt with great Circumspection, for it's a sign that the salts are become very acid, since they offend every part where they lie; you must always stop it by degrees, for fear a sudden suppres­sion might again revive the Fever, and render it more malignant and pernicious, which would presently unite Putrefaction with Inflammati­on. The Flux being stopt, the Pa­tient must be fed with sweet and thick Food.

The proper Medicines for stop­ping a Flux are Clysters made of White Broth, Mallows, Bran, Let­tice, Knot-grass, and the Yolk of Eggs. Tisans made of Bugle, Sa­nicle, Lemons, and Liquorish, are also of great help.

We observe, that this Flux hap­pens oftner in great Hospitals, than any where else, especially in great Wounds, because the Wounded re­ceive there an Air loaden with Ma­lign and Pestilential Vapours, which not only causes the Looseness, but all the other troublesome Accidents which follow upon it.

We observe, that the Wounds which happen to the Legs are most dangerous, or of difficult cure, but since the Circulation being more flow in them, their Tendons and Membranes stretched, and their Ve­sicles more narrow, this disposi­tion of parts causes the Humours to settle and employ themselves more easily, and that only the serosity is able to disengage it self in time of their settlings, by its abode changes into a Virulent Sanies, which enter­tain the Wounds of these hard and callous parts. They also require some Medicines capable of carrying off, and melting the Callosity, and destroying the Sanies which is the chief cause of it.

When Wounds are of difficult cure, and as it were unconquerable with Medicines, it's the evil dispo­sition of the Subject for the most part which contributes to it. Some are naturally of an Ill Habit, others affected with some Venerial Dis­ease, or some other as bad; Finally, others do not govern themselves, and have a greater inclination for that which is hurtful to them, and which is capable of heating and al­tering their Blood; If in these kinds of Inconveniencies the Medicines which we have used produce not any effect, Cardiac's and Medicines of a Purifying Quality favours their cure;What to be used in Venomous Wounds. as all Aromatic's, Cordial Potions, all Preparations of Mercury and Antimony, Theriac, Confecti­ons, Powder of Vipers, with their Volatil Salt, Volatil salt of Hearts-horn, and several Medicines of the same Nature, which differently, ac­cording to the different degrees of Corruption.

This is the Practice which must be followed in Venomous Wounds, having applied upon the part all things that resist Mortification. [Page 324]These are more or less mortal ac­cording as the malignity, activity, and penetration of the Acid Humour (wherein consists the Nature of Poy­son) are more or less great and fa­tal.

CHAP. III. Of Wounds of the Tendons.

I Have made you observe, speak­ing of the Suture of the Ten­dons, that when it's quite cut, there happens no troublesome accident but that it retires towards its Origine, and that one is obliged to soften their Fibres with Oyls drawn without Fire, that their reunion may be the easier.

I have also made you observe, that the Stitch being made, it was neces­sary to Humect the Tendon with Oyl and Spirit of Wine, the Oyl resists the Impressions of the Air, and the Spirit of Wine penetrating the least Porosities, deobstructs their Channels in driving out the Hu­mours, and by this means the con­course [Page 325]of Symptomes, particularly that of Pain is stop'd. Suppuratives must follow next immediately, for­asmuch as they hinder that the In­flammation may not cause long sup­puration, which would infallibly rot the Tendons in spight of all the care that might be taken, as it happens in all great Fluxions, where the Tendons are discovered. This is the reason which obliges us to stay till the Suppuration be accomplished, and the Tendon covered, before we use Dissicatives, as Tinct. Aloes, Spirit. Vini, with several others, because in drying the part too soon you hinder the dissolution of the Juice, stops Suppuration, and retains the Inflam­mation, which is the true cause why the Tendon rots.

The Inflammation which comes upon Wounds of the Tendons that lie but shallow under the Skin, is not dangerous, but since the Juice which exudes out of it is corrosive, it awakes the Pain and all other Accidents which most commonly attend Wounds of the Tendons. But if it happen that a deep Tendon be hurt, the Inflammation and Obstructions [Page 326]are greater, and more troublesome, by reason of the many Sanguin Ves­sels which lie over it.

If the Accidents continue, and the Tendon suppurates not, it's most convenient to dilate the Wound, that the Remedies may be able to pene­trate, and ease the part by causing a speedy suppuration.

If the Flesh which is generated in these kinds of Wounds become cal­lous, it's a sign that the salt abounds every where, and that the fluxions will be great, since the salt particles condense themselves in the very sub­stance of the part. We use only here Digestives and Balsams which are convenient till the Wounds be ready to cicatrise, being capable of melting and dissolving the Juices, by which we know that Dissicatives are noxious because they procure too soon a Cicatrix.

There's sometimes generated a soft spongy Flesh, which threatens the part with great Obstruction; then it's also necessary to continue the Digestives; for Dissicatives glue and harden too much the nourishing particles, and augment the abun­dance [Page 327]of the salts which cause faulty Flesh. In this case SCHRODER's Green Balm is excellent.

You must observe, that a Tendon may be hurt by a prick without any accident happening. This is when the Instrument slips between the In­terval of the Fibres without enda­maging them. But if by chance it divides some of the Fibres, Obstru­ctions follow, which occasions the nourishing Juice to become corrosive, gnawing the Fibres and Membranes, which causes a greater Obstruction, & more violent Pain; Besides the Spi­rits which are irritated by these sharp Matters augment the Inflammation, which at first is not [...] [...]nsiderable, but afterwards very dangerous.

To help this inconvenience, you ought without scruple to open the Te­guments and Flesh to find the place of the prick'd Tendon, and to sweeten the Acrimony of the salts with Ol. Ovor. Cere, and Spirit. Vini, not neglecting at the same time the use of Digestives and Balms. If the Accidents cease not, it's a sign the Puncture is deep, and that the Me­dicaments cannot penetrate; then [Page 328]you must separate dexterously the Fibres of the Tendon according to their length, to give way to the Bal­samic Particles to soften the Fibres, and the Spirit of Wine to discuss the Humours, and cause a more easie Suppuration.

The Inflammation which follows upon the Puncture of a Tendon in­croaches often upon the near parts; as for Example, if the Tendon of the Finger be prickt, the Wrist and Arm swell so much, that one is often obliged to Amputate it. For seeing the Tendon and Belly of the Muscle contain nothing but a heap of Fibres of the same continuity, the Con­vulsions [...] consequently the In­flammation communicates it self not only to the Belly of the Muscle, but also to all the neighbouring parts. You must not be astonished if these parts have such a correspondence to­gether, and if they communicate so mutually one to another their alte­rations. If there be any difference between the Tendon and the Belly of the Muscle, it consists only in their Texture, and in the more or less In­flammation, Tention, or Pain.

The most Specific Remedies to stop the Accidents of a Punctured Tendon, is to give issue to the Wound. If the Tendon lie high, we use Balsamic's and Digestives; but if deep, you must add Spirit of Wine; if the fluxion be great, you apply upon the Tendon a little Boul­ster soaked in Brandy, to secure it from the impression of the Purulent Matter. As concerning Cataplasms it's known, that we apply Emollients, Discutients, and Defensatives, during the first 2 or 3 days, according to the degrees of the Inflammation, af­terwards we prefer Discutients, which are continued all the time of the Fluxion; and during the rest of the Cure you must use Plaisters and Com­presses soaked in Spirit of Wine warm'd.

If the Tendon of the Hand be hurt, we lay not only Defensatives upon the part, but also over the whole Arm. If the Puncture be made with a square or triangular In­strument, it's doubtless more to be feared than that which is made by a flat or round one, because of the great number of the divisions; it [Page 330]therefore requires more Circumspe­ction. Lastly, if the Inflammation be great, and there be appear­ance of a Gangrene, you must Scarifie, and use all that is ca­pable to awake the motion of the Spirits.

CHAP. IV. Of Wounds of the Ligaments and Bones.

WOunds of the Ligaments differ not much from those of the Tendons, but in the more or less sensibility, and though they are not so painful nor dangerous, ne­vertheless it happens very often, that Putrefaction seizes it, by the a­bode of the Purulent Matters upon these parts.

If the Ligaments of the Joynts be hurt, I say that thickning Remedies are most contrary; because we must by all means oppose the coagulation of the viscous and salt Juices which entertain these parts, as also the for­mation [Page 331]of Ganglions and Anchilose, which cannot be mollified nor dis­solved by the most powerful Medi­cines. If the Ligaments of a Joynt cannot be hurt without some Ten­don receiving damage also; it may be easily comprehended, that the In­flammation hinders them from obey­ing the motion of the Muscles, and that the Humours which supple the Ligaments and Glands, are not en­tertain'd in their ordinary fluidity; and as I have shew'd in th [...] Anevrism, that it condenses at the least heat, by the repose of its Particles, and it forms an Anchilose; so I say its for­mation must be much quicker here, the heat being more excessive. Now it's evident, that a concatenation of accidents of this nature may utterly destroy the part; for if the Anchi­lose which grow about the Joynts and Ganglions, which are form'd upon the Ligaments by the thickning and coagulation of the Nutritive Juice, cause the loss of motion; the alteration and mixture of several Li­quors of different nature, are very fit to putrifie it, by their purulancy and acidity.

The Purulent Hmour corrupts and infects it, the Acid pricks and gnaws it, and the Viscous obstructs, and makes it immovable; It's doubtless by reason of the con­trariety of their principles which destroy one another in the actions of the Medicaments, which causes them to be of so difficult a cure, and so hard to prevent the Ligaments from rotting.

We have made you observe in the Examination of the Fistula in Ano, that Wounds of the Joynts often de­generate into Fistula's, because the salt Juice abounds there from every part, and the Pus changes into a sharp and malignant Sanies, which filters into the Porosities of the Ner­vous Fibres of the part, making the Ulcer callous and fistulous; This Humour becomes sometimes so biting, that it destroys not only the Ten­dons and Ligaments, but gnaws also the Cartilages, and causes a Cario­sity of the Bones.

To prevent all this, you must fol­low the same Method which we have prescribed in Wounds of the Tendons, that is to say, you must [Page 333]use every thing that tempers, sweetens, and is capable to correct the acri­mony of the salts.

When the Wound hath run well for some days, and the swelling of the part a little gone down, you use a Balm made of Ox-gall,An Ex­traordi­nary Me­dicine in Wounds of the Joynts, &c. Spirit of Wine, and Mel. Rosat. which hath the faculty of discussing and re­solving the Coagulate Matters. Af­ter this manner you prevent the cal­losity of the Wound, and all other accidents; We commonly Cicatrise with Humecting Medicaments, be­cause Dissicatives make it deform'd.

The Bones differ from the Ten­dons and Ligaments, in that their Contexture is more thick, close, and compact, and are nourished with a more salt and subtil Juice.

If the Wounds which happen to them be simple, the sole reduction of the Pieces maintained by Bandages is sufficient to cure them.

If the Fractured Bones press some Vessel or Tendon, and the Contusi­on be considerable, if you differ the reduction, the part falls into a Gangrene and Mortifies.

If some pieces of the Bone be se­parated, so that you cannot reduce them, you must make an Incision to pull them out. I know that this happens very seldom, and the Splin­ters must the very much intangled in the Flesh, if they cannot be reduced without Incision.

If the Bones be quite broke to pieces, and some great Vessels lace­rated, you must cut off the Limb.

I speak not here of the Dressings which are used in all sorts of Fra­ctures; I only recommend to you that the Bones be tied harder where broke, then any where else, to keep them reduced, and to hinder the Callus from growing too abun­dantly.

We know that Compound Wounds comprehend both those of the Flesh and Bones, and that besides the 18 tail Bandage, they require the ap­plication of several different Reme­dies. We use in the beginning Dis­cutient Cataplasms, to evacuate part of the Matter by Transpira­tion.

You must by all means Suppurate, because we are obliged to wait for the generation of the Callus, and ex­foliation of the Bone, besides a great Suppuration alters the Bones in a very little time.

It's therefore necessary that Dis­cutients be used in stead of Suppu­ratives, and if in the first days we use Digestives, Spirit of Wine and Hony must exceed, you apply dry Lint upon the Bone till the Callus be form'd, and after it's generation you apply Boulsters on it, soaked in Spirit of Wine, in which Sal. Ar­moniac. and Camphire has been dis­solved, which is a most excellent Medicine to cure Ulcers of the Bone, and to hasten Exfoliation.

You must observe, that there ne­ver grows good Flesh upon a rot­ten Bone, or that which is ready to exfoliate; It's always spongy, and one may say, that whenever they are of such a nature, it's a certain sign that the Bone must needs Ex­foliate, which most ordinarily hap­pens in long Suppurations.

The formation of the Callus grows according to the Patients way of Living; It's observed, that it grows too much, and renders the part unequal, when the Patient eats too plentifully, and when they use too spare a Diet, it grows not suffi­cient to reunite the part.

The Prognostic's of Compound Wounds are always very dangerous to Cachectical Persons, Old, and Pox't, whose Bones rot oftentimes without any Wound coming upon them.

CHAP. V. Of Gunshot Wounds.

GUnshot Wounds are always ve­ry dangerous, as well by rea­son of the great Contusion which accompanies them for the most part, as because the passages of the Blood are utterly stopped.

We know that the Bullet's passing through a part scatters the substance, and breaks the Vessels without any [Page 337]Hemorrhagy, or Suppuration before three, four, five, or sometimes six days; the age, temperament, and nature of the part regulate these accidents; the reason of it is grounded upon the great agitation of the Bullet, and upon its round and blunt figure, that enters with so much force and swiftness into the Flesh, bruiseth and crushes the Ves­sels, so that it forceth their Tunicles to glue themselves to one another, and so opposes the flux of Blood, unless some great Vessel be broke, and the Blood force a passage by its Impulsion.Obstru­ction great in Gunshot Wounds. Of all Wounds there's none where the Obstruction is greater than in these, and which consequently are more capable of Inflammation and Gangrene.

The contain several Particulari­ties to which the Chyrurgeon ought to give his attention; The first is, to consider whether they be in any of the Venters, or the Limbs; if superficial or penetrating; if the Bullet hath passed through and through; if it has touched some important part tending to the functions of Life in its passage, [Page 338]which may be known by the suc­ceeding symptomes.

But whether it has passed through, or found some obstacle in its passage, it's well known, that these kinds of Wounds are almost always accom­panied with troublesome accidents,Accidents accompa­nying Gunshot Wounds. as rupture of some Vessel, fracture of a Bone, or Contusion, which is of least consequence.

If the Orifice of the Wound be of a round figure, and grown less by the fluxion; the first Intention which you must satisfie is to dilate it; you excite by that means Suppurati­on, and procure a more equal. Cica­trice; you discharge the part in let­ting the Wound bleed as much as is convenient, and prevent accidents. But first it's important to extract the Bullet, if you can, since it is its pro­gress which marks the place which is to be dilated. If you cannot fol­low the track which it has taken without making an Incision,How to extract the Bul­let. you put the Patient into the same posture he was in when wounded, that you may easier trace the Bullet, and observe the place where it stops; you after­wards dilate the Wound, minding [Page 339]two Circumstances;

• 1. You must a­void the great Vessels;
• 2. You must not discover the Tendons of the Joynts without necessity.

If the Bullet be engaged near some great Vessels,When to leave the Bullet in. or in the middle of the Muscles, so that it cannot be ex­tracted without causing some ill effect, you may leave it in the part, pro­vided the Patient be not much incom­moded with it. If it be in any of the Venters, you must leave it to Nature. If it stick in the Bones, you must gently move it, to draw it out more easily; because the Bone would of ne­cessity putrifie. If it be in the Ner­vous parts, as in the Joynts, you must hasten its extraction, particu­larly when it's sharp, or of any cor­ruptible Matter, for then you must not only extract it from the Nervous parts, but every part whatever.

You extract the strong Bodies by Attraction, or by Impulsion, with the Hand, Instruments or Medicines ac­cording to the part they lie in. If, for Example, a Bullet be passed the great Vessels, you will be obliged to extract it from the opposite part; but if it be on this side, you extract it through its entrance.

Nevertheless that general Rule hath its exception, for if some strange Body be upon the Carpus or Tarsus forc't from without inward, and should have passed the Bones; It would be a great temerity to Incise the bending Tendons of the Fingers, to force a passage through the op­posite. In that case you must extract it by the same way it went it.

If the Bullet has ruin'd a Joynt, you must cut off the part, because the Ligaments and Bones being quite split to pieces, and their Splinters irri­tating the Tendons; it causes a Gan­grene to seize presently on the part.

If the Bone of the Thigh be broken, you must dilate the Wound as much as is convenient, and advance the Suppuration, that you may have the liberty of extracting some pieces of the separate Bones, if there be any; Of the rest you follow the same method as in other Compound Wounds.

If there be any Vessels open'd, as the Subclavian Vessels, you make the Ligature; and if some Blood be dif­fused upon the Diaphragm, you must come to the Operation of Empiema.

If the Bullet has carried off a great part of the Bone, as we cannot cut proportionably so much Flesh as the substance of the Bone lost; for to convey Remedies thither, it happens that the Flesh that grows over it be­comes callous, and sometimes ossified, forasmuch as the salt Juice which runs this way hardens it by little and little.

If the Trunk of a great Vessel be opened, we are often obliged to Am­putate the part, because the part which receives no more Blood for its nou­rishment Gangrenates. If the Wound be only in the Flesh, you may bath it presently after the first dressing with Brandy, you soak Boulsters in it, and bind up the part with Compresses soaked in warm Wine, strengthen'd with Spirit of Wine.

Accidents which at­tend.The chiefest accidents that accom­pany Gunshot Wounds, are Tumours, Putrefaction, and Hemorrhagy, to dis­sipate the swelling we successfully use Traumatic Fomentations mixt with Spirit of Wine, or Cataplasms made of Urine, Rye Meal, Hony, and Infu­sion of Roses, or a Lye made of Vine-Ashes, in which you dissolve Sal Ar­moniac, [Page 342]and Brandy; If the Tumour be not big, Suppuration is enough to carry it off; If it be accompanied with hardness, you make some slight Scarifications.

To excite Suppuration in these kinds of Wounds, you use a Digestive made of Ʋngt. Basilicon, Linament. Arcei, Ol. ovor. & Spirit. Vini; If Cor­ruption be joined, you add Theriac. Myrrh, Aloes, Sal Armoniac. Ol. Absinth. & Anthi; as you fear the Corrupti­on, you animate them the more.

If the Putrefaction happen to a fleshy and spongy part, you dissolve Egyptiac. in Spirit of Wine, and mix it with the Digestive.Egyptiac not to be used in Nervous parts. For Egyptiac. being entirely a Dissicative, if it were used in Nervous parts, that are wont to dry up, it would dissipate the little humidity that remains there. If you use Injections, it's best to use the two Aristolochias boiled in White Wine, in which you dissolve Sugar Candy, Camphire, Myrrh, and Theriac.

Bitter things not to be used in Injections of the Breast.You must observe, that Injections as well as other Remedies must be managed with prudence according to the parts where they are used. Ex. Gr. If you Inject into the Breast [Page 343]of one troubled with an Empiema a bitter and sharp Liquor, it would irritate the part, so that they would augment the accidents; in the like occasion we use with good success a Decoction of Barley, Agrimony, a very little Wormwood, and Cen­taury, Plantain, Birthwort, in which you dissolve Mel. Rosar. If this needs to be fortified, you boil them in Whitewine or Brandy.

The Tincture of Persicaria Ma­culata made with White wine, is al­so good to resist Putrefaction; if you intend to make it stronger, you dissolve Myrrh, Aloes, and Sal Ar­moniac in Brandy; and mix with it the Solution of Sal Armoniac in Spirit of Wine, which produces the same effect; and to hinder the generati­on of new Corruption, you com­pass the Dressing with Spirit of Wine Camphorated; The Solution of a Drachm of Mercurius sublimate, or Arsnic in half a Pint of Spirit of Wine is excellent in great Putre­factions; or one Ounce of Mercury in two Ounces of Aquafortis, which we mix with Lime Water or Brandy.

We also use with very good suc­cess in these occasions, the Solution of the Canstic Stone in Brandy, which we mix with the same quan­tity of Spirit of Wine Camphorat­ed. All these Solutions are capable to waste and separate putrified and rotten Flesh, and also to consume the Cariosity of Bones.

After the effect of all these Re­medies, you use Detorsive Decocti­ons made of red Roses, Consolid. Maj. Quinquesolium, Plantain, Agri­mony, Nettles, Pimpernell, Peri­winckle, St. Johns Wort, Purslain, Plantain, and Poppy Seed; with which you slightly siringe the Wound, so separate the rest of the Impurities that are there.

When you use Detersives, you ordinarily joyn Suppuratives with them, as Turpentine, Ʋnguent. ex apto, Balsam. Arcei, & Ol. Hype­rici.

If the Wound has long suppurat­ed, and the Flesh grows Luxuriant, you consume it with the Spirit of Sulphure put in the Mundificative; If it be the Humidity of the part, [Page 345]which causes this proud Flesh to grow, instead of the Mundificative, you use Allom Water, or the Aq. Phagedenica, or the Decoction of the Traumatic Plants made with Lime Water; or, Lastly, Linamentum Ar­cei, mixt with Myrrh and Fine Bole in Powder.