In almost every fissure, or fracture of the bone, the ancient physicians had immediate recourse to instruments to cut it. But it is far the best method, first to try plaisters that are composed for the skull. Some one of these, it is proper to soften with vinegar, and apply alone upon the fissured or fractured bone; then over that, somewhat broader than the wound, a piece of linen spread with the same medicine, and besides that, sordid wool dipped in vinegar; then to bind up the wound, and open it again every day; and dress it in this manner for five days; from the sixth, to foment it also with the vapour of hot water by a spunge, continuing all the former treatment. And if granulations begin to grow, if the febricula is either gone, or abated, if the appetite has returned, and the patient gets sufficient sleep, we must continue the same dressings. Some time after, the plaister must be softened, with the addition of a cerate made of rose oil, to promote the growth of flesh: for, by itself, it has a repellent quality. By this method often the fissures are filled with a kind of callus, which is as it were a cicatrix in a bone. And in large fractures, if the bones do not cohere together in any part, they are united by the same callus; and this is a far better covering to the brain, than the flesh that grows, when the bone is cut out. If, under the first treatment, the fever increases, the sleeps are short and disturbed by dreams, the ulcer is moist and does not fill, small glandular swellings rise in the neck; the pains are violent; and with all these the loathing of food increases; then, and only in that case, recourse must be had to the hand and the chisel.
There are two dangers attending a blow upon the skull; that it be either split, or depressed in the middle. If it is fissured, the lips of it may be compressed; either because one of them rises above the other, or even because they have run together again with force: whence it happens, that a humour descends upon the membrane, and has no vent, and thus irritates it, and brings on violent inflammations.
When the bone is depressed in the middle, it presses upon that same membrane of the brain; and sometimes also some sharp points from the fracture, prick it. In the cure of these cases as little as possible must be taken off the bone. Therefore, if one edge rests upon the other, it is sufficient to cut off the prominence with a plain chisel. After that is removed, if the fissure gapes a little, it is enough for the cure. But if the edges are compressed together, an opening must be made with the perforator, at a finger’s breadth distance on one side, and from that the chisel must be carried in two lines, to the fissure, in the form of the letter Λ: so that the vertex of it may be at the opening, and the base at the fissure.
But if the fissure extends to a great length, it will be proper to repeat the operation from another foramen; and thus nothing that is broke off can be concealed under the bone, and a large opening is procured for whatever is hurtful within. Nor is it necessary to cut out the whole of a fractured bone, though it be depressed; but if it be either entirely broke through, and has separated wholly from the cranium, or if it adhere to the surrounding skull in a small part, it must be divided from the sound bone by the chisel. Then in the depressed bone, near the fissure we have made, holes must be bored; if the injured part be small, two; if larger, three; and the spaces betwixt these must be cut out; and then the chisel must be drove on both sides to the fissure, in such a manner as to make a semicircular cavity, and let the middle part be toward the fracture, and the horns point to the sound bone. Then if any pieces be loose, and can be easily taken away, they must be removed by the forceps, which is made for that purpose, especially those sharp pieces, which irritate the membrane. If this cannot be easily done, the plate, which I called meningo-phylax, must be put below it; and above that whatever is prickly, and stands inward, must be cut off; and whatever is depressed inward must be raised by the same plate. The effect of such treatment is, that the fractured bones, if they adhere together in any part, may be consolidated; and wherever they are broke away, in time they may be separated by medicines without any pain; and at the same time a space may be left sufficiently large between them, to evacuate the sanies; and the brain may have a better protection from the bone than it would have had, if that were cut out.
After these things are done, the membrane must be sprinkled with sharp vinegar; that, if there be a discharge of blood from it, it may be restrained, or if any blood remain coagulated within, it may be discussed; then the same medicine must be applied, softened in the manner above prescribed, to the membrane itself; the other directions, which relate to the linen spread, and the sordid wool, must be observed in the same manner, and the patient must be kept in a warm place, and the wound dressed every day; and in summer even twice.
But if, by reason of an inflammation, the membrane has swelled, warm rose oil must be infused upon it. If it shall swell to such a height as to rise above the bones, it will be restrained by lentils well powdered, or vine leaves powdered, and mixed with either fresh butter, or recent goose fat; and the neck will require to be mollified by liquid cerate made of iris ointment. But if the membrane shall appear not to be clean, equal quantities of the plaister and honey must be mixed; which must be infused upon it; and to keep that on, a piece of lint or two must be clapped on, and that again covered with a linen cloth spread with a plaister. When the membrane is sufficiently clean, cerate must be added in the same manner to the plaister to promote the growth of flesh.
As to abstinence, and the food, and drink, in the first and more advanced stages of the cure, the same rules must be observed which I prescribed in wounds, and with the greater exactness, by how much a hurt in this part is more dangerous. Nay even when it shall be fit to allow such a quantity of food as not barely to sustain the patient, but to nourish him, yet every thing that requires chewing must be avoided; also smoke, and whatever excites sneezing. The membrane being moveable, and of its natural colour, granulations of ruddy flesh, and an easy motion of the lower jaw and neck, afford certain hopes of recovery. The bad signs are, the membrane immoveable, black, livid, or of any other vitiated colour; a delirium, acrid vomiting, a palsy, or convulsion, livid flesh, or rigor of the jaws and neck. The other symptoms that relate to sleep, appetite, fever, and the colour of the pus, are either salutary or mortal, as in other wounds.
When the case succeeds well, the growth of flesh begins from the membrane itself; or if the bone in that part be double, it sprouts from thence too, and fills up the void space between the bones; sometimes it even rises higher than the surface of the skull. If that happens, copper scales must be sprinkled on to keep it down; and medicines applied to bring a cicatrix over it, which is easily obtained in every place, except the part of the forehead, which is a little above the space that lies between the eyebrows (sinus frontalis): for there, an ulceration for the whole life after, can hardly be prevented; this must be covered with a linen cloth spread with a medicine. And the following directions must be always observed in a fractured skull, that till the cicatrix be strong, the sun, wind, frequent bathing, and excess in wine be avoided.