Three several ways, _viz._ by Contusion, by Incision, and by Puncture.
_What is the most dangerous of these Fractures?_
It is that which happens by Contusion; because the Concussion and Commotion is greater.
_Do all the Fractures of the Skull require the use of the Trepan?_
No, the Fractures must be deep which stand in need of the help of such an Instrument; for those that are superficial may be cur"d by a simple Exfoliation.
_What is that deep Fracture, wherein the use of the Trepan is absolutely necessary?_
It is that which is made in the two Tables of the Skull, penetrating to the _Meninges_ of the Brain; upon which at that time the Blood is diffus"d, and must be taken away by the Operation of the Trepan.
_How may it be discover"d that the two Tables of the Skull are broken?_
By the Eyes, and by Ratiocination.
_Are not the Eyes sufficient alone, and are they not more certain than Ratiocination?_
Yes; but forasmuch as things are not always seen, there is often a necessity of making use of rational Deductions to find out that which the Eyes cannot discern.
_When doth it happen that the Eyes alone discover the Fracture?_
When the Wound is large and wide, so that it may be immediately view"d.
_When doth it happen that Ratiocination supplies the defect of the Eyes?_ {194}
When the Wound is so small that the Bone cannot be seen, and nothing appears but the Accidents.
_What are the Accidents or Signs of the Fracture of the Skull?_
They are a dimmness of the Sight, and loss of the Understanding, which happen at the very Moment when the Fall or Blow is receiv"d; with the Phlegmatick Vomittings that follow soon after: These Signs are call"d _Univocal_. And there are others that bear the Name of _Equivocal_, and which confirm the former; as a Flux of Blood thro" the Nose, Eyes, and Ears, redness of the Eyes, heaviness of the Head, and puffing up of the Face; as also afterward Drowsiness, Shivering of the whole Body, Fever, _Deliriums_, Convulsions, _&c._
_Must all these Signs appear before a Determination can be made of the necessity of using the Trepan?_
No, it is sufficient to have the Univocal Signs to make a Crucial Incision in the place of the Wound, and to lay bare the Bone, in order to observe the Fracture, which sometimes is so fine, that the Operator is oblig"d to make use of Ink, which insinuates it self into the Cleft, and of a particular Instrument, with which the black Line that hath penetrated to the bottom, cannot be rubb"d out; whereas it may be easily defac"d when the Fracture is only superficial.
_How long time is commonly spent before the appearing of the Accidents?_
In the Summer Season they appear in three or four Days, and at the latest in seven; in Winter {195} they are slower, and sometimes do not happen till the fourteenth Day: But at the end of this term, it may be affirm"d that the Trepan is often unprofitable.
_What is requisite to be done in a doubtful Occasion; Must the Trepan be apply"d or omitted?_
The Surgeon is to have recourse to his own conscientious Discretion, which ought to serve as a Guide, and requires that we should always act according to the known Rules of Art; insomuch that after having well consider"d the Accidents, with all the Circ.u.mstances of the Wound, if there be no good grounds for the undertaking of the Operation, it is expedient to desist, and in this case to have deference to the Advice of other able Surgeons of the same Society, rather than to rely too much upon his own Judgment, to the end that he may be always secure from all manner of Blame.
_Is the Trepan apply"d upon the Fracture?_
No; but on one side of it, and always in a firm place.
_What Course is to be taken when a Fracture is found in a Suture?_
A double Trepan is to be made, and apply"d on each side of the Suture, by reason of the overflowing of the Blood, which may happen therein.
_What Method ought to be observ"d in the curing of the Wounds of the Head, and Fractures of the Skull?_
In simple Wounds of the Head, it is necessary only to make use of Balsams, and to lay over "em _Emplastrum de Betonica_. When there is a Contusion either in the {196} _Pericranium_, or in the Skull, the Wound must be kept open till after the Suppuration or Exfoliation.
When there is only a Bunch without any Wound or Accident, it must speedily be dissolv"d with Plaister or Mortar, Chimney-Soot, Oil of Olives, and Wine, laid upon the Part between two Linnen-Rags; or else with Soot, Spirit of Wine, and Oil of St. _John_"s-Wort, wherein the Bolsters are soakt, to be in like manner apply"d with a Band.
Wounds of the Head accompany"d with a Fracture, absolutely require the application of the Trepan, wherein it is requisite to make use of Oil of Turpentine to be dropt upon the Membrane of the Brain; or else Spirit of Wine mingled with Oil of Almonds, and not with the Oil or Syrrup of Roses; and to endeavour to cause a plentiful outward Suppuration.
Besides, it must not be neglected to enjoyn the wounded Person to be let Blood both before and after the Operation, if he hath a Fever or a Plethory; and more especially it is to be remember"d to cause his Body to be kept open at least every other Day, with Clysters, obliging him to keep a good Diet, and to avoid all violent Agitations both of Body and Mind, abstaining from eating Flesh till the Fourteenth Day. All manner of Venery and Conjugal Embraces, which prove fatal at this time, are to be prohibited during forty Days, to be counted from the Day of the Operation; as they are also in all other considerable Wounds.
{197}
CHAP. IV.
_Of the _Caries_ or Ulcer of the Bones, _Exostosis_, and _Nodus_._
_What is_ Caries?
It is the Putrifaction of the Substance of the Bone, or else its Ulcer or Gangrene.
_Whence doth the _Caries_ of the Bone derive its Original?_
It proceeds from an internal and external Cause; the former being that which hath been produc"d at first in the Substance of the Bone; and the other that which takes its Rise from an inveterate Ulcer in the Flesh, which hath communicated its Malignity to the Substance of the Bone, and by that means corrupted it.
_How is the _Caries_ known which proceeds from an inward Cause?_
By the continual and violent Pains which are felt before, and continue for a long time without diminution; as also afterward by the alteration of the Flesh that covers the Bone, and which becomes soft, spongy, and livid.
_By what means is a _Caries_ that derives its Origine from an outward Cause, discover"d?_
By the quality of the purulent Matter that issueth out of the Ulcer in the Flesh, which is blackish, Unctuous, and extremely stinking; as also by the help of the Probe, that discovereth {198} asperity or roughness in the Bone when it is laid bare.
_What Means are to be us"d in order to cure a _Caries_ proceeding from an external Cause?_
The Powder of Flower-de-luce may be us"d, and it is sufficient for that purpose, when the _Caries_ is superficial; but it is necessary to take _Oleum Guyaci_, and to soak Bolsters therein, to be laid upon the Ulcer when it is deep; or else _Aqua-Vitae_ or Brandy, in which have been infus"d the Roots of Flower-de-luce, Cinnamon, and Cloves. Lastly, the actual Cautery, which is Fire, must be apply"d thereto.
_What is to be done when the _Caries_ proceeds from an internal Cause?_
The Flesh must be open"d to give Pa.s.sage to the _Sanies_ that runs out of the ulcerated Bone, to the end that Exfoliation may be procur"d; and if the Ulcer hath not as yet laid open the Bone on the outside, the Trepan ought to be apply"d; but the Ulcer or _Caries_ must be afterward handled, as we have even now declar"d.
_What is _Exostosis_?_
It is the Swelling of a Bone made by the settling of a corrupt Humour in its proper Substance.