SURGERY.

665

to discharge freely : and so soon as the instrument is nearly full ofWood , it should be taken away; which may be always easily doneby raising one side of it, so as to give access to the external air.When more blood is wished to be taken the parts should be bathedWith warm wa’er; and being made perfectly dry, another glass,exactly the size of the former, should be instantly applied in theVery same manner.

Of Issues.

Issues are a kind of artificial ulcers formed in different parts ofthe body with a view to procure a discharge of purulent matter,which is frequently of advantage in different disorders. Practi-tioners were formerly of opinion that issues served as drains toCarry off the noxious humours from the blood, and therefore theylaced them as near the affected part as possible. But as it is nownown that they prove useful merely by the quantity of matterWhich they afford, they are generally placed where they will occa-sion the least inconvenience. The most proper parts for them*re, the nape cf the neck; the middle, outer, and lore part of thehumerus; the hollow above the inner side of the knee; or either•ide of the spine of the back ; or between two of the ribs, or vvlie-e ycr there is a sufficiency of rellular substance for the protectionbf the parts beneath they ought never to be placed over thebelly of a muscle; nor over a tendon, or thinly coveted hone;her near any large biuod-vessel. The issues commonly u-ed are,J-’e hlisler-issue, the p“a-issue, and the seton or cortl. When ablister-issue is to he used, after the blister is removed, a dis-charge of matter may be kept up by dressing the part daily with* n ointment mixed with the powder of cantharides. It the d.-charge be too little, more of the powder may be used ; if toopeat, or if the part be much inflamed, the issue'-ointnient may be* a >d aside, and the part dressed with basilicon, or with Turner’scerate, till the discharge be diminished and the. inflammation abal-c< *. It is most proper sometimes to use the issue-ointment and ahidd one alternately. A pea-issue is formed either bv making anln cis;on with a lancet, or by caustic, large enough to admit one or5) 0r e peas; though sometimes instead of peas, kidney-beans,Gentian root, or orange peas, are used. IVhen the opening i,^Ule by an incision, tht skin should he pinched up and cut through,°* a size sufficient to receive the substance to lie put into it.

The Seton is used where a large quantity of matter is «anted,® n, l especially where it is wished for from deep-seated parts. It is' r,, quei lly used in the back of the neck for diseases of the head or®)'cs, or between two i f the ribs in affections of the breast. Whenle cortl, which is made of threads of cotton or silk, is to be in-^cdiiced, the parts at which it is to enter and pass out should bef'Cviously marked with ink, and a small part of the cord being’Sinewed with some mild ointment, and passed through the eves j ’be seton-needle (fig 13), the part is to be supported by an as-ai 't, and the needle passed fairly through, leaving a few inchesth > con ' banging out. The needle is now to be removed, andPart dressed. By this method matter is produced in quantityr ^’Portioned to the degree of irritation applied ; and this can be, 1 ,. re ‘ lSfc, ( or diminished by covering the cord daily oefore it is"’ n with an irritating or mild ointment.

Of Sutures and Lisatures of Arteries.vi[li "e intention of sutures is to unite parts which have been di-Cotis' ’i aiU ' vv ' lere the retraction of the lips of the wound Ivas beeng eo . ulera ble. The sutures in ordinary use at present, among sur-thpjg , are ‘be interrupted, the quilled, ami the twisted. Besidesw 0Hri .* Wu res, adhesive plasters are used for uniting the lips orsiti 0|) l s ’ w bich have been termed the false or drv suture, in oppo-1)1 0Q( | t0 {be others which leave obtained the 'name of true orthe f a ? ' . * be true suture is used in cases of deep wounds, whileru Pted 6 * nnip'oyed in those of a superficial nature. The inter-th e „ r Sl 'tuie is made as follows: The wound being emptied otlie q„'! llous blood, and the assistant taking care that the lips of itthe even > the surgeon is careful to carry the needles from

0:it fa,, i m outwards; using the caution of making them come^''bbtitcM? 11 ^' bx>m the edge ot the wound, which will not onlyting threw t |) , assi[1 S the ligature, but will also prevent it from cut-WquiPPd ;nV le s bb’ a| td flesh; as many more stitches as may be■eing || ' Vlll _be only repetitions of the same process. The threads

Xoa, passed, let those be first tied which are in the middle of^ tv.— no. turn.

the wound: though, if the lips are held carefully together all thewhile, as they should be, it will be of no great consequence whichis done first. The most useful kind of knot is a single one first,and then a slip-knot, which may be loosened upon any considera-ble inflammation taking place. If a violent inflammation shouldsucceed, loo.-ening the ligature only will not suffice; it must becut through and drawn away, and the wound be traced alterwardswithout any suture. When the wound is small, lire less it is dis-turbed by dressing the better; but in large ones, there will some-times be a considerab'e discharge; and it the threads be not cau-tiously carried through the bottom of it, abscesses will frequentlyensue from the matter being pent up underneath, and not findingissue. If no accident happen, after the lips are firmly aggluti-nated, tlie ligatures are to be removed, and the orifices which theyleave dressed. During the cure the suture must be always assistedby tlie application of bandage, if possible, which is frequently ofthe greatest importance; and that sort of bandage with two heads,and a slit in tiie middle, which is by much the best, will in mostcases be found practicable.

By the term Twisted Suture, is meant that species of liga-ture by which parts, cither naturally or artificially separated, areunited togethei by means of strong threads properly tvv isted roundpins or needles pushed through the edges of tlie divided parts.This suture-is commonly employed for tlie purpose oi uniting theparts in cases of hare-lip ; and this indeed is almost the only useto which it has been hitherto applied : hut it may with great ad-vantage be put in practice in a variety of other cases, particularlyin all artificial or accidental divisions cither of tlie lips or cheeks ;and in every wound in other parts that does not run deep, and inwhich sutures are necessary. The pins used in this operation arerepresented in fig. 14. They are commonly made of gold or sil-ver ; and in order'to make them pass with greater ease, steel-pointsare added to them. They are sometimes used, however, ot goldor silver alone. When a surgeon is called immediately to awound of any great artery of a limb, he should clap tlie point ofhis huger upon the wounded artery, or make his assistant hold it;cut the wound so far open as to see tlie artery fairly; draw it outif it tie cut across, anil have shrunk among tlie flesh ; or tie itlike tlie artery of the arm in aneurism by passing ligatures under it.When, however, the wound happens in smh situations that wecannot command the blood, it is belter to close the lips of thewound, and try to make them adhere by means of a very steadycompress and bandage. Titus an aneurism will form; the opera-tion for the cure ot which shall be afterwards described. Whenaccidents of litis nature occur in any of tlie extremities, and wherepressure can be made with ease on tlie superior part of the ar-tery, we aie possessed of an instrument which never fails to put astop to all further loss of blood: viz. the tourniquet, (fig. 15.)

'1 he tourniquet lias undergone many improvements; but the onehere represented i$ considered as tlie best. Various methods havebeen invented for securing arteries bv means of ligatures. Thepractice till lately in ordinary me was, by means ot a curved nee-dle, to pass a ligature of sufficient strength round the mouth of thebleeding vessel, including a quarter of an inch all round the sur-rounding parts, and alterwards to form a knot of a proper tightnessupon the vessel and oilier parts comprehended in the noose. Buttins method was found to give so much pain, and in some cases tobe attended w ith such violent convulsions, not only ill the partchiefly affected, but of the whole body, that the best practitionersmow reject it, and tie up the blood-vessels by themselves; for it isnow well known that even very small arteries are possessed of muchfirmness; and that even in the largest arteries a slight degree of com-pression is sufficient not only for restraining hannorrhagy, but forsecuring tlie lit attire on the very spot to which it is first applied.To detect the arteries to he lied, the tourniquet, with which theyare secured, must be slackened a little by a turn or two of thescrew ; and the moment the largest artery ot the sore is discovered,tlie surgeon fixes his eyes upon it, and immediately restrains the-blood again by means of tlie tourniquet. An assistant now formsa noose on tlie ligature to be made use of; and this noose beingput over tlie point of the tenaculum, (fig. lb,) the operator pushestlie sharp point of the instrument through tlie sides of the vessel,and at the same time pulls so much of it out, over the surface ofthe surrounding parts, as he thinks is sufficient to be Included in.the knot which the assistant is now to make upon tlie artery. In,8 G forming.