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 Circumstances 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 Passage 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.
_What is _Nodus_?_
It is a kind of gummy and wavering Tumour, which is form'd by the settling
of a gross Humour between the Bone and the _Periosteum_.
_Are _Exostoses_ and _Nodus_'s suppurable Tumours?_
Yes, because they sometimes produce Ulcers and Gangrenes in the Bone, which
are call'd {199} _Caries_, proceeding from an internal Cause; nevertheless
they are generally dissolv'd by Frictions with _Unguentum Griseum_, or by
the application of Plaisters of Tobacco, or _Emplastrum de Vigo
quadruplicato Mercurio_; taking also to the same purpose internal
Diaphoretick and Sudorifick Medicines, with convenient Purgatives.
* * * * *
CHAP. V.
_Of Cauteries, Vesicatories, Setons, Cupping-Glasses, and Leeches._
_What is a Vesicatory?_
The Name of Vesicatory may be attributed to every thing that is capable of
raising Bladders or Blisters in the Skin; nevertheless in Surgery, by a
Vesicatory is understood a Medicament prepar'd with _Cantharides_ or
_Spanish_ Flies dried, which are beaten to Powder, and mingled with
Turpentine, Plaisters, Leaven, and other Ingredients.
_In what places, and after what manner are Vesicatories usually apply'd?_
They are apply'd every where, accordingly as there is occasion to draw out
or discharge some Humour from a Part: In Defluxions of Rheum upon the Eyes
or Teeth, they are laid on the Neck and Temples; in Apoplexies, behind the
Ears; and so of the rest, observing always to make Frictions on the places
where the {200} Application is to be made, to the end that the Vesicatory
may sooner take effect.
_How long time must the Vesicatory continue on the Part?_
The Blisters are generally rais'd by 'em within the space of five or six
Hours; yet this Operation depends more or less upon the fineness of the
Skin; and when the Bladders or Blisters appear, it is requisite to deferr
the openning of 'em for some time, to the end that Nature may have an
Opportunity to introduce a new Scarf-Skin, by which means the Pain may be
avoided that would be felt, if the Skin were too much expos'd to the Air.
_What is a Cautery?_
It is a Composition made of many Ingredients, which corrode, burn, and make
an Escar on the Part to which they are apply'd.
_How many sorts of Cauteries are there in general?_
There are two kinds, _viz._ the Actual and the Potential; the former are
those that have an immediate Operation; as Fire, or a red-hot Iron; and the
others are those that produce the same Effect, but in a longer space of
time; such are the ordinary Cauteries compos'd of Caustick Medicaments.
_Which are the most safe, the Actual or the Potential Cauteries?_
A distinction is to be made herein; for Actual Cauteries are safest in the
Operation, because they may be apply'd wheresoever one shall think fit, as
also for as long a time, or for any purpose: Whereas the Potential cannot
be {201} guided after the same manner. But in Haemorrhages the Potential
Cauteries are most eligible, by reason that the Escar produc'd by 'em not
being so speedily form'd, the Vessels are better clos'd, and they are not
so subject to open again when it falls off; as it often happens in the Fall
of an Escar made by Fire.
_In what places are Cauteries usually apply'd?_
In all places where an Attraction is to be made, or an Intemperature to be
corrected, or a Flux of Humours to be stopt, by inducing an Escar on the
Part: However they are commonly laid upon the Nape of the Neck, between the
first and second _Vertebra_; on the outward Part of the Arm in a small Hole
between the Muscle _Deltoides_ and the _Biceps_; above the Thigh, between
the Muscle _Sartor_, and the _Vastus Internus_; and on the inside of the
Knee, below the Flexors of the Leg; observing every where that the Cautery
be plac'd near the great Vessels, to the end that it may draw out and
cleanse more abundantly.
_What is the Composition of the Potential Cauteries?_
They may be made with quick Lime, Soap, and Chimney-Soot; or else take an
Ounce of _Sal Ammoniack_, two Ounces of burnt _Roman_ Vitriol, three Ounces
of quick Lime, and as many of calcin'd Tartar; mingle the whole Mass
together in a _Lixivium_ of Bean-Cod Ashes, and cause it to evaporate
gently to a Consistence: Let this Paste be kept for use in a dry place, and
in a well-stopt Vessel. Or else the Silver-Cautery, or _Lapis Infernalis_
may be prepar'd after the following manner: {202}
Take what quantity you please of Silver, let it be dissolv'd with thrice as
much Spirit of Nitre in a Vial, and set the Vial upon the Sand-Fire, to the
end that two third parts of its Moisture may evaporate: Then pour the rest
scalding-hot into a good Crucible, plac'd over a gentle Fire, and the
Ebullition being made, the heat of the Fire must be augmented, till the
Matter sink to the bottom, which will become as it were an Oil: Afterward
pour it into a somewhat thick and hot Mould, and it will coagulate, so as
to be fit for Use, if it be kept in a well-stopt Vial. This Cautery is the
best; and an Ounce of Silver will yield one Ounce and five Drams of _Lapis
Infernalis_.
_What is a Seton?_
It is a String of Silk, Thread, or Cotton, threaded thro' a kind of
Pack-Needle, with which the Skin of a Part is to be pierc'd thro', to make
an Ulcer therein, that hath almost the same effect as a Cautery.
_What is most remarkable in the Application of a Seton?_
It ought to be observ'd, that the String must be dipt in Oil of Roses, and
that one end of it must always be kept longer than the other, to facilitate
the running of the Humours.
_In what Parts is the Seton to be apply'd?_
The Nape of the Neck is the usual place of its Application, altho' it may
be made in any part of the Body where it is necessary. It sometimes happens
that a Surgeon is oblig'd to use a kind of Seton in such Wounds made with a
Sword, or by Gun-shot, as pass quite {203} thro' from one side to the
other; then the String or Skain must be dipt in convenient Ointments or
Medicinal Compositions; and as often as the Dressings are taken away, it
will be requisite to cut off the Part soakt in the Purulent Matter, which
must be taken out of the Ulcer.
_What is a Cupping-Glass?_
It is a Vessel or kind of Vial, made with Glass, the bottom whereof is
somewhat broader than the top, which is apply'd to the Skin to cause an
Attraction. There are two sorts of these Cupping-Glasses, _viz_, the Dry,
and the Wet; the former are those that are laid upon the Skin without
opening it; and the latter those that are apply'd with Scarification.
_In what Diseases are Cupping-Glasses us'd?_
In all kinds where it is necessary to make any Attraction; but more
especially in Apoplexies, Vapours in Women, Palsies, and other Distempers
of the like Nature. But the Applications of Cupping-Glasses are altogether
different; for in Apoplexes they are generally set upon the Shoulders or
upon the _Coccyx_; in Vapours upon the inside of the Thighs; and in Palsies
upon the Paralytick Part it self.
_What is a Leech?_
It is an Animal like a little Worm which sucks the Blood, and is commonly
apply'd to Children and weak Persons, to serve instead of Phlebotomy:
Leeches are also us'd for the discharging of a Defluxion of Humours in any
Part; as also in the Haemorrhoidal Veins when they are too full; in the
_Varices_ and in several parts of the Face. {204}
_What choice ought to be made of Leeches?_
It is requisite to take those that have their Backs greenish, and their
Bellies red; as also to seek for 'em in a clear running Stream, and to cast
away those that are black and hairy.
* * * * *
CHAP. VI.
_Of Phlebotomy._
_What is Phlebotomy?_
It is an evacuation of Blood procur'd by the artificial Incision of a Vein
or Artery, with a design to restore Health.
_Which are the Vessels that are open'd in Phlebotomy or Blood-letting?_
They are in general all the Veins and Arteries of the Body, nevertheless
some of 'em are more especially appropriated to this Operation; as the
_Vena Praeparata_ in the Forehead; the _Ranulae_ under the Tongue; the
Jugular Veins and Arteries in the Neck; the Temporal Arteries in the
Temples; the _Cephalick_, _Median_, and _Basilick_ Veins in the inside of
the Elbow; the _Salvatella_ between the Ring-Finger and the Little-Finger;
the _Poplitaea_ in the Ham; the _Saphena_ in the internal _Malleolus_ or
Ankle; and the _Ischiatica_ in the external.
_What are the Conditions requisite in the due performing of the Operation
of Phlebotomy?_
They are these, _viz._ to make choice of a proper Vessel; not to open any
at all Adventures; not to let Blood without necessity, nor {205} without
the Advice of a Physician; whose Office it is to determine the Seasons or
Times convenient for that purpose; as that of Intermission in an
Intermitting Fever; that of Cooling in the Summer; and that of Noon-tide in
the Winter; and lastly, to take away different quantities of Blood; for in
the Heat of Summer they ought to be lesser, and greater in the Winter.
_What are the Accidents of Phlebotomy?_
They are an Impostume, a _Rhombus_, an _Echymosis_, an _Aneurism_,
Lipothymy, Swooning, and a Convulsion.
_What is a _Rhombus_?_
It is a small Tumour of the Blood which happens in the place where the
Operation is perform'd either by making the Orifice too small, or larger
than the Capaciousness of the Vessel will admit. The _Rhombus_ is cur'd by
laying upon it a Bolster dipt in fair Water, between the Folds of which
must be put a little Salt, to dissolve and prevent the Suppuration.
_How may it be perceiv'd that an Artery hath been prickt or open'd in
letting Blood?_
The Puncture of an Artery produceth an Aneurism; and the Opening of it
causeth a Flux of Vermilion Colour'd Blood, which issueth forth in
abundance, and by Leaps.
_Are the Leaps which the Blood makes in running, a certain Sign that it
comes from an Artery?_
No, because it may so happen, that the _Basilick_ Vein lies directly upon
an Artery, the beating of which may cause the Blood of the {206} _Basilica_
to run out leaping: Therefore these three Circumstances ought to be
consider'd jointly, that is to say, the Vermilion Colour, the great
quantity and the Leaps, in order to be assur'd that the Blood proceeds from
an Artery.
_How may it be discover'd that a Tendon hath been hurt in letting Blood?_
It is known when in opening the _Median_ Vein, the end of the Lancet hath
met with some Resistance; when the Patient hath felt great Pain, and
afterward when the Tendon apparently begins to be puff'd up, and the Arm to
swell. A Remedy may be apply'd to this Accident thus; after having finish'd
the Operation, a Bolster steep'd in _Oxycratum_ is to be laid upon the
Vessel, a proper Bandage is to be made, and the Arm must be wrapt up in a
Scarf: If the Inflammation that ariseth in the Part be follow'd with
Suppuration, it must be dress'd with a small Tent; and if the Suppuration
be considerable, it is necessary to dilate the Wound, and to make use of
Oil of Eggs and Brandy, or _Arcaeus_'s Liniment, with a good Digestive; as
also to apply _Emplastrum Ceratum_; to make an Embrocation on the Arm with
Oil of Roses; and to dip the Bolsters in _Oxycratum_ to cover the whole
Part.
_Is it not to be fear'd that some Nerve may be wounded in letting Blood?_
No, they lie so deep that they cannot be touch'd.
_Under what Vein is the Artery of the Arm?_
It is usually situated under the _Basilica_. {207}
_What Course is proper to be taken to avoid the Puncture of an Artery in
letting Blood?_
It must be felt with the Hand before the Ligature is made, observing well
whether it be deep or superficial; for when it lies deep, there is nothing
to be fear'd; and when it is superficial, it may be easily avoided by
pricking the Vein either higher or lower.
_What is to be done when an Artery is open'd?_
If it be well open'd, it is requisite to let the Blood run out till the
Person falls into a _Syncope_ or Swoon, by which means the Aneurism is
prevented; and afterward the Blood will be more easily stopt: It remains
only to make a good Bandage with many Bolsters, in the first of which is
simply put a Counter or a Piece of Money; but a bit of Paper chew'd will
serve much better, with Bolsters laid upon it in several Folds.
_If the Arteries cause so much trouble when open'd accidentally, why are
those of the Temples sometimes open'd on purpose, to asswage violent Pains
in the Head?_
By reason that in this place the Arteries are situated upon the Bones that
press 'em behind; which very much facilitates their re-union.
_Are not the Arteries of Persons advanc'd in Years more difficult to be
clos'd than those of Children?_
Yes. {208}
_Are there not Accidents to be fear'd in letting Blood in the Foot?_
Much less than in the Arm; because the Veins of the _Malleoli_ or Ankles
are not accompany'd either with Arteries or Tendons; which gave occasion to
the Saying, _That the Arm must be given to be let Blood only to an able
Surgeon, but the Foot may be afforded to a young Practitioner_.
* * * * *
{209}
A
TREATISE
OF
_Chirurgical Operations_.
* * * * *
CHAP. I.
_Of the Operation of the Trepan._
This Operation is to be perform'd, when it is inferr'd from the Signs of
which we have already given a particular Account, that some Matter is
diffus'd over the _Dura Mater_. The Trepan must not be us'd in the _Sinus
Superciliares_, by reason of their Cavity; nor in the Sutures, in regard of
the Vessels that pass thro' 'em; nor in the Temporal Bone without great
necessity, especially in that part of it which is join'd to the
Parietal-Bone, lest the end of this Bone shou'd fly out of its place, since
it is only laid upon the Parietal; nor in the middle of the Coronal and
Occipital-Bones, by reason of an inner {210} Prominence wherein they adhere
to the _Dura Mater_; nor in the Passage of the Lateral _Sinus's_ that are
situated on the side of the Occipital.
If the Fissure be very small, the Trepan may be apply'd upon it, altho' it
is more expedient to use this Instrument on the side of the Fissure in the
lower part; neither is the Trepan to be set upon the Sinkings; and if the
Bones are loosen'd or separated, there needs no other trepanning than to
take 'em away with the Elevatory.
The Operation must be begun with Incision, which is usually made in form of
a Cross, if the Wound be remote from the Sutures, and there are no Muscles
to be cut, and in the shape of the Letter T. or of the Figure 7. if it be
near the Sutures, so that the Foot of the 7. or of the T. ought to be
parallel to the Suture, the top of the Letter descending toward the
Temples; it is also made in the middle of the Forehead. If it be sufficient
to make a longitudinal Incision in the Forehead; its Wrinkles may be
follow'd, and there will be less Deformity in the Scar; but it is never
done Crosswise in this Part, and the Lips of the Wound are not to be cut.
If an Incision be made on the Muscle _Crotaphites_, and on those of the
back-part of the Head, it may be done in form of the Letter V. the Point of
which will stand at the bottom of the Muscles; nevertheless it is more
convenient to make a longitudinal Incision, by which means fewer Fibres
will be cut; and it is always requisite to begin at the lower part, to
avoid being hindred by the Haemorrhage. {211} The Incisions are to be made
with the Incision-Knife, and that too boldly when there are no Sinkings;
but if there be any, too much weight must not be laid upon 'em: Thus the
Incision being finish'd, the Lips of the Skull are to be separated either
with the Fingers, or some convenient Instrument; Then if there be no urgent
Occasion to apply the Trepan, it may be deferr'd till the next Day, the
Wound being dress'd in the mean time with Plaisters, Bolsters, Pledgets,
and a large Kerchief or upper Dressing, the use of which we shall shew
hereafter.