SURGERY

672

the skin immediately brought over the orifice, and retained therebv a slip of adhesive plaster.

Rv disopHAGOTOMY is understood the cutting open the (eso-phagus, to allow substances sticking in it, and which cannot beextracted otherwise, to lie removed. It is only to be done, how-ever, in cases of the most extreme danger, as it is attendedwith much hazard; and there are only two instances yeton record of its having been performed with success, thoughthere are several instances of wounds in the oesophagus beinghealed.

Of Sore Nipples.

Women are more generally affected with sore nipples in suck-ling their first child than at any period afterwards. This may insonic measure he owing to the smallness of the nipples; but veryoften it arises from their being unaccustomed to the irritation ofsucking. In some cases, the nipples are so flat, and so muchsunk in the breast, as to render it difficult for the child to lay boldof them. Assistance can sometimes be given, by the motherpressing back the prominent part of the breast, so as to make thenipple project between two of her fingers. If this prove insuffi-cient, the nipple may be made to project by applying to it a stoutchild several months old : but when this cannot be done, breast-glasses, such as Plate CLXVI. fig. 6k, may answer the purpose.By applying these to the nipple, and sucking out the air, the child•will commonly be enabled to lay hold of it. The nipples areliable to excoriations, cracks, or chops; which, though not at-tended with a formidable appearance, are often more distressingthan large ulcers. Mild, astringent, and drying, applications aremost to be depended upon m such cases; as port wine,brandy diluted, or lime-water; all to be applied warm. Afterbathing the parts with any of these, the nipple should be coveredwith unguentum nutritum, or Goulard’s cerate ; the first of whichis considered as best. Even soft pomatum often rubbed upon thepart, and covered with a soft linen-rag, will give considerable re-lief. But the nipple should be perfectly cleared of these applica-tions, before the child is laid to the breast, by port-wine, or equalparts of brandy and vinegar.

Of Paracentesis of the Abbomen, or Tapping.

This operation is an opening made into the abdomen, to emptyany quantity of extravasated water collected in that species ofdropsy called the ascites. Upon the supposition that nothing for-bids the extraction of the water, the method of operating is this:having placed the patient in an horizontal situation, as best suitedto prevent fainting, and to allow the water to run freely off, thepart to be perforated ought to be marked with ink ; ami the mostapproved part of the operation seems to be at a point lying atnearly an equal distance between the umbilicus and the centre ofthe spine of the os ilium, this being most out of the way of anyof the viscera, and sufficiently depending to allow the 'water toescape; and as the spleen is less frequently enlarged than theliver, the left side is generally preferred. Various means havebeen used for applying an equal pressure in this operation. Someapply pressure by the hands of assistants; others use a broadpiece of flannel, or other cloth, slit a certain way from each end ;then the ends are drawn by assistants till sufficient pressure ismade. Broad belts are used by some practitioners; but one ofthe best contrivances for this purpose is the bandage invented byDr. Monro , (fig. 70.) Till very lately, a puncture was firstmade with a lancet, then a trocar of a round form (fig. 71,) witha triangular point, was constantly used: but the entrance of thisinstrument being always attended with difficulty and pain, a fiattrocar is now very frequently employed: and that invented byMr. Andree, (fig. 69,) seems the best which has yet appeared.The bandage being now applied and drawn a little tight, the partto be punctured is to project a little over the edge of the bed.The operator fixes the head of the trocar in the palm, while thefore-finger directs the point of the instrument, lie is then topush it forwards till he is satisfied, by the want of resistance, thatthe end of the canula has reached the cavity of the abdomen.The perforator is now to be withdrawn, and the water allowed toflow as long as any of it can be taken off, the bandage being fromtime to time pulled to favour the discharge. JJut if the patient

become faint, a stop for a few minutes should be put to thedischarge every now and then, by placing the point of the fingerupon the mouth of the canula. If any of the viscera happen tostop the flow of the water before the swelling is much diminished,a blunt probe is to be introduced, but bent at the end, lest it slipinto the cavity of the abdomen. When the serum is thick andgelatinous, it may sometimes he necessary to introduce a largertrocar than the one first employed. When the water does notflow, because it is collected into cists, the canula is to be with-drawn, and the wound covered with a pledget of simple ointment.The operation may then be renewed immediately, or on the fol-lowing day, upon the opposite side of the abdomen, or in themost depending part of the tumor, in whatever part of theabdomen it may be placed.

Of IIernije.

The name of IIernije might with propriety be applied toevery swelling occasioned by the dislodgement of parts fromthose boundaries within which, in a state of health, they are con-tained ; but the general acceptation of the term implies a tumorproduced by the protrusion of some part or parts from the cavityof the abdomen. The parts in which hernia; usually appearare the groin, scrotum, labia pudendi, the upper and fore-part of the thigh, the umbilicus, and different points betweenthe interstices of the abdominal muscles. If the situation ofsuch tumors he various, the viscera which produce them arestill more so ; instances having occurred of the stomach, ute-rus, fiver, spleen, and bladder, being found to form their con-tents. lint a part of the intestinal canal, or a portion of theomentum, are from experience known to be the most frequentcause of their formation.

From these circumstances of situation and contents, all the dif-ferent appellations are derived by which hernia; are distinguished.Thus they are termed inguinal, scrotal, femoral, umbilical andventral ; from their appearing in the groin, scrotum, thigh, navel,or belly. When Hie tunjor is confined to the groin, the hernia issaid to bo incomplete, and is termed bubonocele ; but when theswelling reaches down to the bottom of the scrotum, the ruptureis then supposed to be complete, and the disease obtains the nameof scrotal rupture, or Oscheocele. In whatever situation a pro-trusion of any portion of the intestines occurs, except in the her-nia congenita, as all the viscera are contained within the perito-nienm, a portion of that membrane, it is evident, must be carrieddown together with the parts protruded; and in every such instance,it is this portion of the peritoneum which goes down along withthe gut, that is termed the hernial sac. '1 lie size of this sac isvarious in different subjects, and in different stages of the samedisorder. On the first appearance of the disease, it is commonlyof no very considerable size, as such swellings seldom acquire ail/great bulk at once: but by repeated descents of the bowels, Rcomes to be pushed lower and lower, till in some instances its bulkbecomes very considerable indeed ; and when in this advancedperiod of the disorder the sac happens to be laid open, it i*found to contain either large quantities of omentum or intestineor frequently large portions of each. In that kind of herm 11called chronic, the circulation of the part forming the hernia, aSwell as the peristaltic motion of such parts of the alimentary canalas have been protruded, go freely and regularly an. There art’many instances of large hernia; falling down even to the bottomthe scrotum, and continuing there for many years, without p r0 'ducing any interruption to the usual discharge by stool. All thafcan be done here is, to prevent any accumulation of fa-ces in th®.intestine, by prescribing a proper diet, and the occasional usegentle laxatives; and obviating any inconvenience which mig^arise from the weight of the tumor, by the application of a prop e ^truss or suspensory bandage; to warn them of the risk to whichthey are constantly liable, and to caution them against violent eX cr 'cise, particularly leaping, and every sudden exertion. The trus*ought to be fitted exactly to the part for which it is intended, 1°'without the utmost nicety in this respect, it must always do m° r ^harm than good: for the sole purpose of a bandage, in cases 0hernia, is to prevent effectually the falling down of such parts ahave been newly replaced. It therefore the pad or bolster of t"bandage does not bear properly against the opening upon which 1is placed, a portion of gut may slip out, and be materially injeff