Chirurgorum comes, or, The whole practice of chirurgery begun by the learned Dr. Read ; continued and completed by a Member of the College of physicians in London.

CHAP. XVI.

Of Shaping the Graft, so as it may represent the Nose.

THE shaping of the Graft consists principally in three things, viz. In forming the No∣strils and the Bridge, in its Insition, and last of all in conforming the whole Graft according to Na∣ture's Model. Nothing of this kind must be attempted, till four∣teen days are over from the Graft's Cutting off, and then it will be time to begin this Operation. In the mean time the Graft must be carefully guarded by Medicaments and binding. Tents, as we said before, must be dipt in unguentum ex succis or ex pompholyge, either alone or mixt together, and put into the Nostrils. But the end of the Graft, that is, the fresh Wound, requires Suppuration for the first Week; and the later Week unguentum ex succis or de pompholyge may be applied. The Artist must also take care, that the external parts cicatrize neat∣ly. He may accomplish this by several means, of which I shall mention the most experienced and successful. They are either Plai∣sters applied outwardly, or Fomen∣tations used before the Plaisters are applied. In Summer time ceratum diaphaenicinum and ex cerussa are proper. It will be better, both for the comeliness of the Cicatrice, and the strength of the part, if a little oleum de Beta be mixt with it. And this is no ordinary Plai∣ster; ℞ Styrac. liqu. ℥ iiij. cerae flavae ℥ij. thuris, myrrhae, oliba∣ni, ligni aloes à ℥ v. redigantur singula in tenuissimum pollineni, & oleo amygd. dulc. recenti, & cera cum resinae, q. s. ex arte pa∣retur ceratum. But before we ap∣ply the Plaister, we have often with good success fomented the part with generous Wine warm, in half a Pint whereof five Grains of Musk were steept. The Graft may be fomented either with a Sponge or with Rags dipt in this Wine, which, when their warmth begins to fail, must be changed for new. For so the Pores are opened, and the Blood is drawn into the Graft. This done, the Artist must cover the whole Skin, and the Nose also, a Fingers breadth, with his Plai∣ster. In the Winter and Autumn

we Foment with this; ℞ Vini Cretic. lb ij. oliban. styrac. li∣quid. an. ʒ j. adipis asini ʒ ij. In∣fundantur omnia per noctem in vi∣no Cretico supra dicto, deinde his ebulliant, mox colentur & colata serventur. Ceratum Barbarum is good. And this; ℞ Galbani, opopanac. thur. aristoloch. long. ma∣stic. myrrh. an ℥ j. Ammoniac. ℥jss. litharg. aur. ol. commun. an. ℥xviiij. bdel. ʒ ij. lap. calamin. haematit. an ℥j. olei absmth. ℥ iiij. terebinth. lb v. ol. rosac. ℥ j. redigantur in tenuissimum pollinem quae religenda sunt, & gummi aceto dissolutis cum cera, s. a. f. ceratum. This also is excellent good, ℞ Aristoloch. rotund. been alb. & rubr. an. ℥ v. rad. lil. ℥ v. cicer. rubr. lupinor. combustor. an. p. s. nucis moschat. cinnam. an. ʒ ss. amygd. amar. con∣tusar. ℥ ij. ol. tartar. ℥ iij. aqu. pluvial. lb. ii. contrita distillentur, mox ℞ liquoris ℥ ij. ol. caryophyll. de spic. an. ℥ j. Styrac. liquid. ℥ v. ambr. ℈j. mastich. ʒ ij. terebinth. ℥ v. bulliant olea cum liquore, de∣inde additis reliquis cum cerae q. s. f. ceratum. s. a. Another thing re∣quisite to the guard of the Graft, is the Binding, which must not be inartificial. For because the Graft must come as near the shape of the Nose as may be, it is requisite to make it gradually pliant, to bend it a little, and to form the Tip and the Bridge. In Nature's Model of the Nose there are these things con∣siderable, the Length, the Tip, the Bridge, ••he Alae or sides of the Nostrils, and the Holes or Nostrils themselves. The length of the Nose is reckoned to be the third part of the Face's length, namely the spac•• between the Tip-end of the Nose to the middle of the interci∣lium is equal to that of the Fore∣head from thence, and to the space between the bottom of the Bridge, and the end of the Chin. The Tip is the round end of the Nose. From hence the Bridge is inserted transverse to the upper Lip; and its length is the space between that insertion and the edge of the up∣per Lip. The proportion of the Alae or sides is such, as that they pass on either side down to the upper Lip in the shape of an (S), only the bought is far larger where it descends to the upper Lip. The Holes or Nostrils are of an Oval Figure, more acute towards the Tip, and more obtuse towards the lower end. After this Mo∣del of Nature therefore must we always form the Cutaneous Graft, when ever the Bridge and the Alae are cut off. And if any part of them remains, the Graft must be formed proportionable. When therefore the Artist would shape the Nose, having first con∣sidered its length, let him mark that part with Ink, which he designs for the Tip. Then let him mark the Confines of the Alae, from the Basis to the Tip; and then mark the Bridge from the same Tip to the Basis. When he has done this, let him consider well, whether all things be exact, and then let him take his Knife, which must be very sharp, and cut, as he had design∣ed, the Graft. But he must ob∣serve this caution in the Section, to the Bridge he must cut in a right line, but towards the Alae in a bow, deep and oblique. He must put small Tents dipt in Whites of Eggs into the Nostrils,

and he must bring the Bridge be∣tween them. Then he must put an orbicular Compress below the Nose. This is done to keep the Bridge from starting, and the Tents from slipping out. He must not take away these Tents till the next day. And take this for a rule in forming the Bridge, always take it long enough and broad enough; for one may take away from it, but can never add to it. There∣fore of the two extreams the ex∣cess is less dangerous than the de∣fect. The reason why the Bridge is cut in a streight line, and the Alae in an oblique or sloping in∣wards, is because this is best both for the Nostrils and the Bridge. For whatever is taken from the thickness of the Alae, as much is added to the Amplitude of the Nostrils. And we may do it the more boldly, because proud Flesh is apt to grow there. Besides, when the Ulcer is healed, the Skin turns inwards, and so the circumference of the Alae being Skin and not a Cicatrice looks the handsomer. The reason why we Cut the Bridge streight down, is, because so it is the stronger, which would otherwise fade away. But the Cutaneous Graft must be well hollowed out towards the Alae, otherwise you can ne∣ver make a decent Nose. Where∣fore whether there be proud Flesh or any thing superfluous of its substance, it must be taken away thus. The Patient must sit against the light, and lean his Head back upon one of the Assistents. Then the Artist having turned up his Nostrils, and diligently viewed whether there be any thing super∣fluous; if there be, he must take it away by little and little and very moderately with keen little Knives. He must repeat this of∣ten, for upon Cutting, proud Flesh is apt always to arise, the growth whereof must be checkt with Tents dipt either in unguentum isidis or de pompholyge, and clapt into the Nostrils, as soon as the proud Flesh is taken away. Every day the Tents must be twice taken out and new ones dipt afresh put in their room, having first wiped the Nostrils with Cotton or soft Wool. Let the Artist have an Eye to the largeness of the Ca∣vity, and if it be not big enough, let him not fear to cut out enough to enlarge it, till the Graft be proportionable to Nature. To this action I can assign no cer∣tain term, I commit it to the Artist's prudence. Only let him take care, while he turns his Knife inward, that he no way hurt the Bridge. For its tender sub∣stance could not bear it. There∣fore the safest way is never to turn the edge of the Knife that way; but to begin the Section at the Tip, and when he is gone half way, to take the Knife out, and put it in at the Lip, and so make the Sections meet. For if he should carry the Knife round and it should slip, it might endanger the Bridge. You need not fear that this tormenting work will spoil the Graft; on the contrary the oftner it is Cut, the harder and stiffer it grows, when once it is Cicatrized. The time of Cicatri∣zation is uncertain, somtimes three weeks (which is soonest,) som∣times, Forty, Fifty or Threescore

days and above; according as the season or the Patient's Constituti∣on is hotter or colder, drier or moi∣ster. But this time needs not seem long, since the Patient may all this while go abroad, and live at his Liberty, provided he abuse it not by excess. The warm Air cannot injure him, but a cold one may; wherefore in Winter and Autumn he must be the more careful.