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. VIII.

The manner of taking up the Cutanous Graft.

IN the Graft there is a twofold Superficies, the natural, which is smooth, and well-coloured; and the ascititious, which is uneven and red. Therefore the Graft must be so applied to the curt parts, that the natural Superficies may be out∣ermost. Besides, it is to be con∣sidered, at which end it must be cut, so as to be best fitted to the Part; If the Nose or upper Lip must be supplied, then the upper end toward the Armpit must be cut; If the neather Lip, then the lower end next the Elbow must be cut. But as to the administra∣tion of the Section, it is twofold; either it is right from the inner angle of the Graft, to the outer Superficies; or it is sloping from the inner Angle of the Graft, to∣wards the Shoulder, somtimes so, as to take in an Inch and an half more of Skin. For when we find that the delineation of the Graft falls short, and that it shrinks, then is the time to eak what it wants by an oblique or slant Secti∣on. Because Nature endeavours Unition, as much as she can, at both ends of the Graft, which shorten it much. And when the Skin is loose and thin, this Section is proper, as we may gather by its shrinking in breadth. But when there is no ground for Fear, then a right Section, without any slo∣ping is best.

The Patient must be set on his Bed, in the same place and po∣sture,

as we advised for the deline∣ation of the Skin, against the Light, at a distance from the Wall, and on the side of the Bed, for the more convenience of the operati∣on. The assistents must observe their stations; one at the Artists right hand, the other at his left. the one must hold the Patients Arm leaning on Pillows, with the Hand upright, from the Elbow: The other must handle the Hume∣rus, according as the Artist shall direct, and as the Graft must be cut right or sloping. If the Ar∣tist make a right Section, he must order the Assistent at his right hand to compress the Skin next the Graft. For often the Skin gives way, and hinders the right Section. Now the Assistent will hold the Skin right, if he put one hand under the Armpit, and the other as near as he can to the Cutaneous Graft. Then the Ar∣tist must with a Probe lift up the Cutaneous Graft, putting his left Forefinger underneath, and car∣rying his left Thumb over against it, let him hold the Graft gently up. Then let him take the knife in his right hand, and cut even, and at a right Angle upwards. When the Graft is taken up, let him turn it back toward the El∣bow, and guard it well with Lint, where it is wounded. For som∣times, when a Vein is cut, it will bleed much. And this is the man∣ner of right Section. But in the oblique or sloping Section, the Assistent lays no hand on the Pa∣tient's Arm, only the Artist puts his knife between the Graft and the Muscle, underneath, and cuts slanting upwards. Assoon as he has considered how much he will add to the Graft, let him take it up between his right Thumb and Fore-finger, and give it to the Assistent at his right hand to hold. He must then put his Probe un∣der the Graft, putting gently un∣der it his left fore-finger, laying his Thumb over against it, and then he must raise the Skin gent∣ly, so as the knife may have room to go in. Which he must take in his right hand, and with some strength cut slanting, as far as he shall think good. When the Graft is taken up, he must turn it back to the Elbow, and where it was cut off, he must cover it with Lint, and fence it well. But he may immediately commit this to be done by his assistent. And the Artist himself may look to the other Part, may lay on Lint, and take care by all means to stop the bleeding. Then my advice is, to cover the whole Bed with divers Liniments, and then to lay on the broad linen Cloth. He may give the Graft to the Assistent on his left hand, who may conveniently hold it in his right, and, with warm linen Cloaths, keep it constantly from the injuries of the Air. In the mean time, the Artist must be covering the whole Bed, by rol∣ling it with one Roller, whose end must be fastned with a needle and thread on the outside of the Arm. When this is done, let him lay some Ointment over the Roller, as far as the cutaneous Graft will reach, and then let him lay back the Graft upon it. Great care must be taken to spread it well both in length and breadth. When the Graft is turned back, laid

smooth, and placed as it ought, the Artist must order an Assistent to lay his middle and fore Finger on the top of it, and bid him take care that it shrink not. Then let him take another Roller, and apply it where the Graft grows to the Stock, and there begin to roll, till he has covered the whole Graft, and bound it to the Arm. Here is the difficulty of the business: For if the Graft be bound too tight, it dies; if too slack, it shrinks. Therefore great care must be taken herein. And be∣cause it is difficult to hit right at first, the Artist, that he may be sure, must, whenever he opens the the Part, diligently take notice of the whole Substance of the Skin, whether it be as it ought, or whe∣ther it dies, or shrinks. This the Eye will shew; the other is known by paleness and senselesness. Be∣cause an Error herein is very hard to amend, therefore I would by all means advice the Artist to be care∣ful in it. When all is done, he must place the Arm in a middle posture, as before. And so the Administration of this Operation is performed.

Here it will not be amiss to mark out the parts of the Graft, and assign to them, and to some other things, names, that when we have occasion to mention them, we may not use Circum∣locutions. Horticulture directs us best in giving Names. For from it the best hints of any such ope∣ration were taken, and by it we have been hitherto directed. All therefore that is the subject of our operation, we call the Graft, the Cutaneous Graft, the Propagmous Skin, or the Brachial Skin. Its length and breadth are conside∣rable; but so is not its depth. The length exceeds the breadth usual∣ly one Third. The length we may divide into three parts, the upper, middle and lower, and we may give every one its name. By the upper part we mean that, which was last cut from the Arm, which we call the top of the Graft. We might more properly call it the insititious end or top, because it is ingrafted into the cut parts. The lower part, which grows to the Arm, we may call the root of the Graft; for from hence Ali∣ment is carried into the rest of the Graft, as from the Root into the Tree. What is between the Top and the Root, we may very well call the body of the Graft. As to the Superficies, we call it either Internal or External, the Inside or Outside, or the later we may call the Cutanous Side. The edges of the Graft we call either Interror or Exterior, or the In∣ternal or External linear Con∣fines, We may properly enough call them Lips; because both in roundness and thickness, they much resemble the Lips of the Mouth.

This we thought fit to mention concerning Names, that all con∣fusion might be avoided, and ob∣scurities cleared, which might otherwise arise about Names.