fixing of the Pyramid or Pin which is in the Round; afterward the Round is
to be apply'd, holding the Handle of the Trepan with the Left-hand, and
turning with the other very fast in the beginning; but when the Round hath
made its way, it is lifted up to remove the Pin, lest this Point shou'd
hurt the _Dura Mater_: Thus the Round being taken off from time to time, to
be cleans'd from the Filings that stick thereto, is set on again, and the
Operator begins his Work of turning anew, which must be carry'd on gently
when any Blood appears, to the end that the first Table of the piece of
Bone which is remov'd may not fly from the second: When it comes near the
_Dura Mater_, the Operator must proceed, in like manner, gently, searching
with a Feather round about the Bone, to observe whether he still continueth
his Course in the Skull. He must also often lift up the Trepan to search
the Hole, to cleanse the Instrument, and to keep {212} it from growing hot.
As often as the Trepan is taken off, let him search with a Feather, to see
whether the Bone be cut equally; and if it be not, he must lean more on
that side which is least cut. If it be necessary to make use of the
_Terebella_, the Hole must be made in the beginning, whilst the Bone is as
yet firm; and when the Piece begins to move, the _Terebella_ is to be put
very gently into its Hole, without pressing the Bone, to draw it out; or
else it may be taken away with the Myrtle-Leaf, which is an Instrument made
of a firm Silver-Plate somewhat crooked. When the Piece is thus remov'd,
the uneven Parts that remain at the bottom of the Hole, are to be cut with
the _Lenticula_; and if there be any Sinkings, they may be rais'd with the
Elevatory. Whereupon the _Dura Mater_ may be compress'd a little with the
_Lenticula_, to facilitate the running out of the Blood, the Wounded Person
being oblig'd to stoop with his Head downward, stopping his Nose and Mouth,
and holding his Breath for a while, to cause the Matter to run out: Then
the _Dura Mater_ may be wip'd with Lint; but if any _Pus_ or corrupt Matter
lies underneath, it must be pierc'd with a Lancet wrapt up in a Tent, that
it may not be perceiv'd by the Assistants. Afterward a _Sindon_ or very
fine Linnen Rag dipt in a proper Medicament, is put between the _Dura
Mater_ and the Skull; the Hole is fill'd with small Bolsters steept in
convenient Medicinal Liquors; and the Wound is dress'd with Pledgets, a
Plaister, and a Kerchief. {213}
But the Hole ought to be well stopt with Bolsters, because the _Dura Mater_
is sometimes so much inflam'd, that it bursts forth; so that if any
Excrescences arise therein, and go out of the Hole, having small Roots,
they may be bound and cut; but if their Roots be large, they must be
press'd close with little Bolsters steept in Spirituous Medicines. Here it
may not be improper to observe, that the Operation of the Trepan ought to
be perform'd more gently in Children than in adult Persons, in regard that
their Bones are more tender, and that Oily Medicines must not be us'd, but
Spirituous. The Exfoliation is made sometimes sooner, and sometimes later;
but the _Callus_ usually covers the opening of the Skull within the space
of forty or fifty Days, if no ill Accident happens. In great Fractures,
where there is no longer any connexion between the Bones, it is requisite
to take 'em away.
_Of the Bandage of the Trepan._
The proper Bandage to be us'd after the Operation of the Trepan, is the
great Kerchief, which is a large Napkin folded into two parts after such a
manner that the side which toucheth the Head exceeds that which doth not
touch it in the breadth of four Fingers; it is apply'd to the Head in the
middle, whilst a Servant holds the Dressing with his Hand: Then the two
upper ends of the Napkin being brought under Chin, the Surgeon takes the
two lower, and draws 'em streight by the sides, so as that side the Napkin,
which is four Fingers broader {214} than the other, may be laid upon the
Forehead: Afterward the two ends of the Napkin are cross'd behind the Head,
and fasten'd at their Extremities with Pins, without making any Folds, that
might hurt the Part; but the ends of the Napkin which fall upon the
Shoulders, are rais'd up to the Head near the lesser Corner of the Eyes;
and the two ends under the Chin are fasten'd with Pins, or else tied in a
Knot.
* * * * *
CHAP. II.
_Of the Operation of the _Fistula Lachrymalis_._
This Operation is perform'd when there is a Fistulous Ulcer in the great
Corner of the Eye, after this manner: The Patient being plac'd in a
convenient Posture, and having his sound Eye bound up, to take away the
sight of the Instruments; the Operator causeth the other Eye to be kept
steady with a Bolster held with an Instrument, and makes an Incision with a
Lancet in form of a Crescent upon the Tumour, taking care to avoid cutting
the Eye-Lid and the little Cartilage which serves as a Pulley to the great
Oblique Muscle. If the Bone be putrify'd with a _Caries_, an Actual Cautery
may be apply'd thereto, using for that purpose a small Funnel or Tube,
thro' the Canal of which the Cautery is convey'd to the Bone. {215} But the
Bone must not be pierc'd, for it is exfoliated entire by reason of its
smallness; and so the Hole is made without any Perforation.
_The Dressing and Bandage of the _Fistula Lachrymalis_._
The Wound is fill'd with small dry Pledgets, and cover'd with a Plaister
and Bolster: The Bandage is made with an Handkerchief folded
triangular-wise, the ends of which are fasten'd behind the Head. If the
Flesh grows too fast, it may be consum'd with the _Lapis Infernalis_; and
if there be occasion to dilate the Wound, to facilitate the Exfoliation, it
may be done with little pieces of Spunge prepar'd, and put into it.
Afterward Causticks are to be us'd, to eat away the Callous Parts, which
may be mingled with Oily Medicines, to weaken their Action, taking care,
nevertheless, that the Eye receive no dammage by 'em. If the Bone be
corrupted, a little _Euphorbium_ may be apply'd; or else the small Pledgets
steept in the Tincture of Myrrh and Aloes; then the Ulcer may be handled as
all others.
* * * * *
{216}
CHAP. III.
_Of the Operation of the _Cataract_._
This Operation is perform'd when there is a small Body before the Apple of
the Eye, which hinders the Sight from entring into it; but it is undertaken
only in Blew, Green, and Pearl-colour'd Cataracts, or in those that are of
the Colour of polish'd Steel; and not in Yellow, Black, or Lead-colour'd.
To know whether the Cataract be fit to be couch'd, the Patient's Eye must
be rubb'd; so that if the Cataract remains unmoveable, it is mature enough;
but if it changeth its place, it is requisite to wait till it become more
solid. The Spring and Autumn are the most proper Seasons for performing the
Operation.
To this purpose the Patient being set down with his Eyes turn'd toward the
Light, and having his sound Eye bound up, the Surgeon must likewise sit on
a higher Seat, whilst the Patient's Head is held by a Servant; and his Eye
being turn'd toward his Nose, is kept steady with a _Speculum Oculi_, which
is a little Iron-Instrument made like a Spoon, pierc'd in the middle, so
that the Ball of the Eye may be let thro' this Hole: Then the Surgeon
taking a Steel-Needle either round or flat, accordingly as he shall judge
convenient, perforates the Conjunctive at the end of the Corneous Tunicle,
on the side of the little Corner of the {217} Eye, and boldly thrusts his
Needle into the middle of the Cataract, which he at first pusheth upward,
to loosen it with the Point of the Needle; and then downward, holding it
for some time with his Needle below the Apple of the Eye. If it ascend
again after it is let go, it must be depress'd a second time; but the
Operation is finish'd when it remains in the same place whereto it was
thrust; neither is the Needle to be remov'd till this be done, and the
Cataract entirely couch'd. In taking out the Needle, the Eye-Lid must be
pull'd down, and press'd a little over the Eye.
_The Dressing and Bandage,_
Is to cause both the Patient's Eyes to be clos'd and bound up; then he must
be oblig'd to keep his Bed during seven or eight Days, and some Defensative
is to be laid upon the sore Eye, to hinder the Inflammation.
M. _Dupre_, Surgeon to the Hospital of _Hotel-Dieu_ at _Paris_, a Person
well vers'd in these kinds of Operations, hath observ'd, that after the
same manner as Cataracts were form'd in a very little space of time in
perfect Maturity; it happen'd also very often, that the Cataracts which
were suppos'd to have got up again, were not the very same with those that
were couch'd, but rather a new _Pellicula_ or little Skin, which sometimes
hath its Origine in the top of the _Uveous_ Tunicle, and is caus'd only by
a very considerable Relaxation of the Excretory Vessels from the Sources of
the Aqueous Humour which in filtrating permits the running {218} of many
heterogeneous Parts, the Encrease of which produceth a new Cataract.
_Of other Operations in the Eyes._
Sometimes a sort of purulent Matter is gather'd together under the Corneous
Tunicle; so that to draw it out, the Eye must be fixt in a Posture with the
_Speculum Oculi_, and after a small Incision made therein with a fine
Lancet, is to be press'd a little, to let out the Matter; but if it be too
thick, it may be drawn forth by sucking gently with a small Tube or Pipe,
having a little Vial in the middle, into which the Matter will fall as it
is suck'd out.
Sometimes a small Tumour ariseth in the Eye, which being ty'd at its Root
with a Slip-Knot, to streighten it from time to time, will at length be
dissolv'd: But if the Tumour lie in the Hole of the Apple of the Eye, this
Operation must not be admitted, lest the Scar shou'd hinder the Passage of
the Light. Sometimes also a somewhat hard Membrane, call'd _Unguis_,
appears in the great corner of the eye, which when it sticks thereto, may
be cut off by binding it; this is done with a Needle and Thread, which is
pass'd thro' the Membrane, and afterward ty'd.
If the Eye-Lids are glu'd together, a crooked Needle without a Point may be
threaded, and pass'd underneath 'em; then the ends of the Thread may be
drawn, to lift up the Eye-Lids, and they may be separated with a Lancet.
{219}
If the Hairs of the Eye-Lids or Eye-Brows offend the Eye, they must be
pull'd out with a Pair of Tweezers or Nippers; and when any small, hard,
and transparent Tumours arise in the Eye-Lids, they are to be open'd, to
let out the corrupt Matter.
* * * * *
CHAP. IV.
_Of the Operation of the _Polypus_._
This Operation is necessary, when there are any Excrescences of Flesh in
the Nostrils, which, nevertheless, when they are livid, stinking, hard,
painful, and sticking very close, must not be tamper'd with, because they
are Cancers. But if they are whitish, red, hanging, and free from Pain, the
Cure may be undertaken after this manner: Take hold of the _Polypus_ with a
Pair of _Forceps_, as near its Root as is possible, and turn 'em first on
one side, and then on another, till it be pull'd off. If the _Polypus_
descends into the Throat, it may be drawn thro' the Mouth with crooked
_Forceps_; and if an Haemorrhage shou'd happen after the Operation, it may
be stopt by thrusting up into the Nostrils certain Tents soakt in some
Styptick Liquor; or else by Syringing with the same Liquor.
* * * * *
{220}
CHAP. V.
_Of the Operation of the _Hare-Lip_._
This Operation is perform'd when the Upper-Lip is cleft; but if there be a
great loss of Substance, it must not be undertaken; neither ought it to be
practis'd upon old nor scorbutick Persons, nor upon young Children, by
reason that their continual Crying wou'd hinder the re-union. But if any
are desirous that it shou'd be done to these last, they are to be kept from
taking any rest for a long time, to the end that they may fall a-sleep
after the Operation, which is thus effected:
If the Lip sticks to the Gums, it is to be separated with an
Incision-Knife, without hurting 'em; then the Hare-Lip must be cut a little
about the edges with Sizzers, that it may more easily re-unite, the edges
being held for that purpose with a Pair of Pincers, whilst the Servant who
supports the Patient's Head, presseth his Cheeks before, to draw together
the sides of the Hare-Lip: Whereupon the Operator passeth a Needle with
wax'd Thread, into the two sides of the Wound, from the outside to the
inside at a Thread's distance from each. But care must be had that the two
Lips of the Hare-Lip be well adjusted, and very even; the Thread being
twisted round the Needle by crossing it above.
{221}
_The Dressing and Bandage._
After the Lips are wash'd with warm Wine, the Points of the Needles must be
cut off, small Bolsters being laid under their ends; then the Wound is to
be dress'd with a little Pledget cover'd with some proper Balsam, putting
at the same time under the Gum a Linnen Rag steep'd in some desiccative
Liquor, lest the Lip shou'd stick to the Gum, if it be necessary to keep
'em a-part. Lastly, upon the whole is to be laid an agglutinative Plaister,
supported with the uniting Bandage, which is a small Band perforated in the
middle; it is laid behind the Head, and afterward drawn forward, one of its
ends being let into the Hole which lies upon the Sore: Then the two ends of
the Band are turn'd behind the Head upon the same Folds where they are
fasten'd, sticking therein a certain Number of Pins, proportionably to the
length of the Wound.
The Patient must be dress'd three Days after; and it is requisite at the
first time only to untwist half the Needle, loosening the middle Thread if
there be three; to which purpose a Servant is to thrust the Cheeks somewhat
forward. On the eighth Day the middle Needle may be taken off, if it be a
young Infant; nevertheless the Needles must not be remov'd till it appears
that the sides are well join'd; neither must they be left too long, because
the Holes wou'd scarce be brought to close.
* * * * *
{222}
CHAP. VI.
_Of the Operation of _Bronchotomy_._
This Operation becomes necessary, when the Inflammation that happens in the
_Larynx_ hinders Respiration, and is perform'd after this manner:
The Wind-Pipe is open'd between the third and fourth Ring, above the Muscle
_Cricoides_, or else in the middle of the Wind-Pipe; but in separating the
Muscles call'd _Sternohyodei_, care must be had to avoid cutting the
recurrent Nerves, lest the Voice shou'd be lost; as also the Glandules
nam'd _Thyroides_. The Space between the Rings is to be open'd with a
streight Lancet, kept steady with a little Band, and a transverse Incision
is to be made between 'em: Before the Lancet is taken out, a Stilet is put
into the Opening, thro' which passeth a little Pipe, short, flat, and
somewhat crooked at the end, which must not be thrust in too far, for fear
of exciting a Cough. This Pipe hath two small Rings for the fastening of
Ribbans, which are ty'd round about the Neck; and it must be left in the
Wound till the Symptoms cease. Afterward it is taken away, and the Wound is
dress'd, the Lips of it being drawn together again with the uniting
Bandage, which hath been already describ'd.
* * * * *
{223}
CHAP. VII.
_Of the Operation of the _Uvula_._
When the _Uvula_ or Palate of the Mouth is swell'd so as to hinder
Respiration or Swallowing, or else is fallen into a Gangrene, it may be
extirpated thus: The Tongue being first depress'd with an Instrument call'd
_Speculum Oris_, the Palate is held with a _Forceps_, or cut with a Pair of
Sizzers; or else a Ligature may be made before it is cut; and the Mouth may
be afterward gargl'd with Astringent Liquors.
* * * * *
CHAP. VIII.
_Of the Operation of a Cancer in the Breast._
The Cancer at first is not so big as a Pea, being a small, hard, blackish
Swelling, sometimes livid, and very troublesome by reason of its Prickings;
but when it is encreas'd, the Tumour appears hard, Lead-colour'd, and
livid, causing in the beginning a Pain that may be pretty well endur'd, but
in the increase it grows intolerable, and the Stink is extremely noisome.
When it is ready to Ulcerate, the Heat is vehement, with a pricking
Pulsation; and the Veins round about are turgid, being {224} fill'd with
black Blood, and extended as it were the Feet of a Crab or Crey-Fish, till
Death happen. When this Tumour is not ulcerated, it is call'd an _Occult
Cancer_; and an _Apparent_ one when it breaks forth into an open Ulcer.
To palliate an Occult Cancer, and prevent its Ulceration, a Cataplasm or
Pultis of Hemlock very fresh may be apply'd to the Part. All the kinds of
Succory, the Decoction of _Solanum_ or Night-shade; the Juices of these
Plants, as also those of Scabious, _Geranium_ or Stork-Bill, _Herniaria_ or
Rupture-Wort, Plantain, _&c._ are very good in the beginning. River-Crabs
pounded in a Leaden-Mortar, and their Juice beaten in a like Mortar, are an
excellent Remedy; as also are Humane Excrements or Urine destill'd, and
laid upon the Occult Cancer: Or else,
Take an Ounce of calcin'd Lead, two Ounces of Oil of Roses, and six Drams
of Saffron; let the whole Composition be beaten in a Mortar with a Leaden
Pestle, and apply'd. The Amalgama of _Mercury_ with _Saturn_ is likewise a
very efficacious Remedy.
In the mean while the Patient may be purg'd with black Hellebore and
_Mercurius Dulcis_, taking also inwardly from one Scruple to half a Dram of
the Powder of Adders, given to drink, with half the quantity of
Crab's-Eyes: But very great care must be taken to avoid the Application of
Maturatives or Emollients, which wou'd certainly bring the Tumour to
Ulceration. {225}
When the Cancer is already ulcerated, the Spirit of Chimney-Soot may be
us'd with good Success; and the Oil of Sea-Crabs pour'd scalding hot into
the Ulcer, is an excellent Remedy. But if it be judg'd expedient entirely
to extirpate the Cancer, it may be done thus:
The sick Patient being laid in Bed, the Surgeon takes the Arm on the side
of the Cancer, and lifts it upward and backward, to give more room to the
Tumour; then having pass'd a Needle with a very strong Thread thro' the
bottom of the Breast, he cuts the Thread to take away the Needle, and
passeth the Needle again into the Breast, to cause the Threads to cross one
another. Afterward these four ends of the Threads are ty'd together, to
make a kind of Handle to take off the Tumour, which is cut quite round to
the Ribs with a very sharp Rasor. The Cutting is usually begun in the lower
Part to end in the Vessels near the Arm-Pit, where a small Piece of Flesh
is left, to stop the Blood with greater Facility: Then having laid a Piece
of Vitriol upon the Vessels, or Bolsters soakt in styptick Water; the sides
of the Breast are to be press'd with the Hand, to let out the Blood and
Humours; and an Actual Cautery is to be lightly apply'd thereto.
_The Dressing._
The Wound is to be dress'd with Pledgets strew'd with Astringent Powders, a
Plaister, a Bolster, a Napkin round the Brest, and a Scapulary to support
the whole Bandage. {226}
But instead of passing Threads cross-wise, to form a Handle, with which the
Breast may be taken off, it wou'd be more expedient to make use of a sort
of _Forceps_ turn'd at both ends in form of a Crescent, after such a manner
that those ends may fall one upon another when the _Forceps_ are shut. Thus
the Surgeon may lay hold on the Breast with these _Forceps_, and draw it
off, after having cut it at one single Stroak with a very flat, crooked,
and sharp Knife. Neither is it convenient to apply the Actual Cautery to
stop the Haemorrhage, because it is apt to break forth again anew, when the
Escar is fall'n off,
When the Tumour is not as yet ulcerated, a Crucial Incision may be made in
the Skin, without penetrating into the Glandulous Bodies; then the four
Pieces of the Glandules being separated, the Cancerous Tumour may be held
with the _Forceps_, and afterward cut off. If there be any Vessels swell'd,
they may be bound before the Tumour is taken away; but if the Tumour sticks
close to the Ribs, the Operation is not usually undertaken.
* * * * *
{227}
CHAP. IX.
_Of the Operation of the _Empyema_._
This Operation is perform'd when it may be reasonably concluded that some
corrupt Matter is lodg'd in the Breast, which may be perceiv'd by the
weight that the Patient feels in fetching his Breath; being also sensible
of the floating of the Matter when he turns himself from one side to
another.
If the Tumour appears on the outside, the Abcess may be open'd between the
Ribs; but if no external Signs are discern'd, the Surgeon may choose a more
convenient place to make the Opening. Thus when the Patient is set upon his
Bed, and conveniently supported, the Opening is to be made between the
second and third of the Spurious Ribs, within four Fingers breadth of the
Spine, and the lower Corner of the _Omoplata_; to this purpose the Skin is
to be taken up a-cross, to cut it in its length, the Surgeon holding it on
one side, and the Assistant on the other. The Incision is made with a
streight Knife two or three Fingers breadth long, and the Fibres of the
great Dorsal-Muscle are cut a-cross, that they may not stop the Opening.
Then the Surgeon puts the Fore-Finger of his Left-hand into the Incision,
to remove the Fibres, and divides the Intercostal Muscles, guiding the
Point of the Knife with his Finger to pierce the _Pleuron_, for fear of
wounding {228} the Lungs, which sometimes adhere thereto, the Opening being
thus finish'd, if the Matter runs well, it must be taken out; but if not,
the Fore-Finger must be put into the Wound, to disjoyn those Parts of the
Lungs that stick to the _Pleuron_.
To let out the Matter, the Patient must be oblig'd to lean on one side,
stopping his Mouth and Nose, and puffing up his Cheeks, as if he were to
blow vehemently; then if Blood appears, a greater quantity of it may be
taken away than if it were Matter, in regard that a Flux of Matter weakens
more than that of Blood. It is also worth the while to observe, that in
making the Incision, the Intercostal Muscles ought to be cut a-cross, that
the side of the Ribs may not be laid bare, by which means the Wound will
not so soon become Fistulous.
If it be judg'd that purulent Matter is contain'd in both sides of the
Breast, it is requisite that the Operation be done on each side; it being
well known that the Breast is divided into two Parts by the _Mediastinum_:
But in this case the two Holes made by the Incision must not be left open
at the same time, for fear of suffocating the Patient.
_The Dressing and Bandage._
The Wound is dress'd with a Tent of Lint arm'd with Balsam, being soft, and
blunt at the end, which enters only between the Ribs, for fear of hurting
the Lungs; but a good Pledget of Lint is more convenient than a Linnen
{229} Tent, however a Thread must be ty'd to the Pledget or Tent, lest it
shou'd fall into the Breast; and Bolsters are to be put into the Wound; as
also a Plaister or Band over the whole. This Dressing is to be kept close
with a Napkin fasten'd round the Breast with Pins, and supported by a
Scapulary, which is a sort of Band, the breadth of which is equal to that
of six Fingers, having a Hole in the middle to let in the Head: One of its
ends falls behind and the other before; and they are both fasten'd to the
Napkin. Thus the Patient is laid in Bed, and set half upright. If the Lungs
hinder the running out of the Matter, a Pipe is us'd, and the Wound
afterward dress'd according to Art.
* * * * *
CHAP. X.
_Of the Operation of the _Paracentesis_ of the Lower-Belly._
This Manual Operation is sometimes necessary in a Dropsie, when Watry
Humours are contain'd in the Cavity of the Belly, or else between the
Teguments. The Disease is manifest by the great Swelling; and the Operation
is perform'd with a Cane, or a Pipe made of Silver or Steel, with a sharp
Stilet at the end; altho' the Ancients were wont to do it with a Lancet.
The Patient being supported, sitting on a Bed, or in a great Elbow-Chair,
to the end that the Water may run downward, {230} a Servant must press the
Belly with his Hands, that the Tumour may be extended, whilst the Surgeon
perforates it three or four Fingers breadth below the Navel, and makes the
Puncture on the side, to avoid the White-Line; but before the Opening is
made, it is expedient that the Skin be a little lifted up. The pointed
Stilet being accompany'd with its Pipe, remains in the Part after the
Puncture; but it is remov'd to let out the Water; and a convenient quantity
of it is taken away, accordingly as the Strength of the Patient will admit.
The Stilet makes so small an Opening, that it is not to be fear'd lest the
Water shou'd run out, which might happen in making use of the Lancet,
because there wou'd be occasion for a thicker Pipe. When a new Puncture is
requisite, it must be begun beneath the former; but if the Waters cause the
Navel to stand out, the Opening may be made therein, without seeking for
any other place.
_The Bandage and Dressing_
Are prepar'd with a large four-double Bolster kept close with a Napkin
folded into three or four Folds, which is in like manner supported by the
Scapulary.
_The Operation of the _Paracentesis_ of the _Scrotum__
Is undertaken when those Parts are full of Water, after this manner: Assoon
as the Patient is plac'd in a convenient Posture, either {231} standing or
sitting, the Operator lays hold on the _Scrotum_ with one Hand, presseth it
a little to render the Tumour hard, and makes a Puncture, as in the
_Paracentesis_ of the _Abdomen_. In an _Hydrocele_ that happens to young
Infants, the Opening may be made with a Lancet, to take away all the Water
at once: But in Men, especially when there is a great quantity thereof, it
is more expedient to do it with the sharp-pointed Pipe; but the Testicles
are to be drawn back, for fear of wounding 'em with the Point of the
Instrument.
If the _Hydrocele_ be apparently _Encysted_, the Membrane containing the
Water is to be consum'd with Causticks, which is done by laying a Cautery
in the place where the Incision shou'd be made, and afterward opening the
Escar with a Lancet.
When the Puncture is made, it ought to be done in the upper-part of the
_Scrotum_, because it is less painful than the lower, and less subject to
Inflammation.
* * * * *
CHAP XI.
_Of the Operation of _Gastroraphy_._