Chapter VI: Part 6

The simple Fracture is that whereby the Bone is broken, without any other Accident; and the complicated Fracture is that which is follow'd by some Accident; as that in which there is a splitting of the Bone in pieces, or {189} where the Bone is broken in two several places, or else when the Fracture is accompany'd with a Luxation, a Wound, an Inflammation, or other Circumstances of the like Nature.

_Are old Men or Children most subject to these Fractures of the Bones?_

Old Men, because their Bones are drier; whereas those of Infants are almost Cartilaginous, and yield or give way to the violence offer'd to 'em; from whence proceed the sinkings and hollowness that happen in their Skulls, especially in the Mould of their Heads, or elsewhere; for which a Remedy is found out by the means of Plaisters, Splints, and Bandages, fitted to the shape of the Parts. It is also on the same Account that Bones are more easily broken in the Winter than in the Summer.

_In what Parts are the Fractures of Bones most dangerous?_

They are those that happen in the Skull and Joints; in the former by reason of the Brain; and in the latter in regard of the Nervous Parts.

_What Course is to be taken by a Surgeon who is sent for to cure a Fracture?_

He ought to do three things, that is to say, at first he must incessantly endeavour to reduce it, to the end that Nature may re-unite the Parts with greater Facility, and that its Extremities may be brought together again with less trouble, before a Swelling, Inflammation, or Gangrene happen in the Part. Afterward he is to use means to retain the Parts in their proper Figure, and {190} natural Situation, and to prevent all sorts of Accidents.

_How is the setting of a broken Bone to be perform'd?_

When the Fracture is Cross-wise, it must be reduc'd by Extension and contra-Extension; and when it is in length, the Coaptation or bringing together again of the Sides, is only necessary.

_What is to be done in a Fracture complicated with a Wound?_

The Operator must first reduce it, and then administer the other Helps, as in a simple Fracture.

_How may it be known that the reducing of the Fracture is well perform'd?_

When the Pain ceaseth; when the Part hath resum'd its natural Shape; when no Unevenness is any longer perceiv'd therein; and when it is conformable to the sound Part on the other side.

_What are the Signs which shew that the Splints remain in the Fracture after it hath been reduc'd?_

They are the secret and continual Workings of the Fibres, or twitchings, that are felt by Intervals in the Part, with great Pains, which are the Indications of an Abcess arising therein; and when a Wound is join'd to the Fracture, the Lips of it are puff'd up, and become more soft and pale, the purulent Matter abounding also more than ordinary.

_When the Splints appear, must they be drawn out by force?_ {191}

By no means; for great care ought to be taken to avoid all manner of violent Operations; it being requisite to wait for their going out with the purulent Matter; or at most to facilitate their Passage by the use of Injections of the Tincture of Myrrh and Aloes; by the application of _Emplastrum Andreae Crucii_, and by the help of the _Forceps_.

_How is a simple Fracture to be dress'd, after it hath been reduc'd?_

The Parts are to be strengthen'd and consolidated with Liniments of _Oleum Lumbricorum_, or of Oil of St. _John_'s-Wort mingled with Wine, Brandy, or _Aqua-Vitae;_ with Fomentations of Red Roses, Rosemary, and St. _John_'s-Wort boil'd in Wine; and with _Emplastrum contra Rupturam_, or _de Betonica_, carefully wrapping up the broken Member, but after such a manner that the two Extremities may not cross one another; and that a small Space may remain open between both. Afterward the Splints and Bands are to be apply'd, taking care to avoid binding 'em too hard, and to take 'em off every three Days, in order to refit 'em, to abate troublesome Itchings, and to give Air to the Part; by these means preventing the Gangrene, which might happen by the Suffocation of the natural Heat. If the Thighs or Legs are broken, Scarves are to be us'd to support and stay 'em in the Bed.

_What space of time may there be allow'd for curing the Fracture of a Bone?_

The Cure will take up more or less time, according to the variety of the Parts, or the different thickness of the Bones: Thus to form {192} the _Callus_ of the broken Jaw-Bone, twenty Days may well be allotted; for that of the Clavicle, or that of the Shoulder-Bone, twenty four; for that of the Bones of the Elbow, thirty; for that of the Arm-Bone, forty; for that of the Wrist-Bone, and those of the Fingers, twenty; for that of the Ribs, twenty; for that of the Thigh-Bone, fifty; for that of the Leg-Bone, forty; for that of the Bones of the _Tarsus_ and Toes, twenty.

_What ought to be done in particular to promote the formation of the _Callus_?_

The fractur'd Part must be rubb'd with _Oleum Lumbricorum_ and Spirit of Wine heated and mingled together: The Decoctions of Agrimony, Sayine, and Saxifrage are also to be us'd, and the _Lapis Osteocolla_ is a Specifick: It is usually given in great Comphrey-Water, or in a Decoction of Perewinkle made with Wine, and is often re-iterated.

* * * * *

CHAP. III.

_Of the particular Fractures of the Skull._

_What is a Fracture of the_ Cranium _or Skull?_

It is a Wound of the Head complicated with a Fracture of the Skull-Bone.

_After how many manners may the Skull be fractur'd?_ {193}

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 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.

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{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.

The Operation is begun with the Perforative, to make a little Hole for the 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.