Part 27 (1/2)

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, s.h.i.+vering 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.