Ars chirurgica a compendium of the theory and practice of chirurgery in seven books ... shewing the names, causes, signs, differences, prognosticks, and various intentions of curing all kinds of chirurgick diseases ... : to which is added Pharmacopoeia chirurgica, or, The medical store, Latin and English ... / by William Salmon ...

CHAP. XXI. DIVIDING of BONES.

I. Trepaning, or Perforation.

I. WHere it is needful to apply the Trepan, it ought to be done as soon as possibly it may; viz. on the third, fourth, or fifth day, lest the putrefying Blood should cause greater E∣vils, but to know whether it be needful to be applied or not, is our first enquiry, because it is an Operation of great danger.

II. It is of great Ʋse when the Bones are very foul; but of great∣est use where ill Symptoms fol∣low a Fissure, or Fracture of the Skull, or a Contusion.

III. Yet a Fissure, or a Fracture, simply considered, require not the Trepan, as an Instrument without which they cannot be Cured: and a slight Contusion does not al∣ways cause such dangerous Symptoms as that Operation of Trepaning does; a small quan∣tity of extravasated Blood, be∣ing oftentimes in strong People discussed by the strength of Na∣ture it self.

IV. Now as Blood is oftner ex∣travasated between the Dura Ma∣ter, and the Pia Mater, than in other places; so there the Trepan can do but little good; but in this Case Barbett would advise to di∣vide the Dura Mater; for that Experience has evinced, that by the help of Art, an Incision, yea a Gangrene of the Part it self has been Cured.

V. So that for the most part, the Trepan is required but in three cases; 1. Where the loose pieces of the Bones prick and wound the Meninges. The signs are a con∣tinual pricking pain, from the very moment of hurt (if the Sick be sensible, if not, he is al∣ways feeling the Part affected with his Hands:) There are likewise Contortions of the Membranes of the Eyes, and Con∣vulsions of the Limbs; to which add, the Quality of the Instru∣ment making the Fracture.

VI. 2. Where the first Table is only depressed, but the second bro∣ken, there being no way to remove the pieces how well soever separa∣ted, but by this of Trepaning. The signs are Dimness of Sight, Gid∣diness, Fever, Vomiting, fee∣ble Pulse, especially about the Temples, and sometimes an A∣poplexy.

VII. 3. Where there is an Ex∣travasation of Blood, upon which follows Putrefaction, and if not soon remedied, Death. The signs are a Continent Fever, Head in∣flamed, Restlesness, unquiet Sleep, Watchings, Inflammati∣ons of the Eyes, and a light Delirium: And if the Sick be Sanguine, there are also Laugh∣ing, Talxing idly, Redness of the whole Face: If Cholerick, Yellowness of Face and Eyes, great Heat, Madness: If Fleg∣matick,

the Symptoms are less, but accompanied with a Palsie or Apoplexy: If Melancholick, there are Fear, Laughing, and Impertinent Talk.

VIII. The manner of Trepaning is thus; the Hair being shaved, let the Skin be divided with a double Incision in form of a Cross, to the Pericranium, avoid∣ing with the greatest diligence always the Temporal Muscles, and Sutures of the Head.

IX. This done, bind up the Wound, unless the Haemorrhage be small (which sometimes is so vio∣lent as to hinder the Artist for some days from his Work) if it will then give leave, divide the Pericranium from the Skull: After a few Hours (the Skull being bare of the Pericranium) let the Patient be well placed, his Head firmly held, and his Ears stopt with Cotton.

X. Then set on the Trepan with a Pin, which ought neither to be upon the Fracture, nor the Su∣tures, (as some have done it) and holding the Instrument with the Left Hand, with the right gent∣ly turn the Trepan about, till it has taken good hold round; now take out the Pin, and set on the Trepan again without it, moving it still about.

XI. If there be any filings of the Skull, take off the Trepan, and wipe them away; the Trepan you may sometimes Oil, that it may go the easier: and sometimes wet it with Water, that it may not grow hot.

XII. If Blood appears, be sure the Trepan has past the first Ta∣ble, after which you must have greater care, lest it unawares should slip in, and wound the Meninges, from whence often∣times follows sudden Death.

XIII. The Dura Mater invests the inside of the Skull, in the same manner as the Pericranium doth the outside, but is not so strongly joined to it, but that a Fall or Blow may easily separate them.

XIV. The piece of Bone sepa∣rated by the Trepan, beginning to be loose, with a little Instrument, viz. the Levatory put in between the Skull and the Trepan, free it from the hole, and take it out with a pair of Forceps.

XV. If any inequality yet re∣main in the inside of the inward Table, which may hurt the Me∣ninx, take it away with the Len∣ticular, or Scraper. The coa∣gulated Blood and Matter take away with Spunges, Lint, &c.

II. Scraping, Filing and Sawing.

XVI. Parts of the Bones are removed by Scraping, which is of use in Fissures and foul Bones, as also in the Teeth, being crusted over with a Blackish, Tartarous Substance. The Bones are to be scraped till you come to the sound Part, which is white and solid; upon the Bone thus scra∣ped, strew some Pouder.

XVII. But before you go about this Operation, you must separate the Pericranium and Periostium; for they are no ways to be touched with Instrument, nei∣ther the Lips of the Wound.

XVIII. 2. By Filing. This is chiefly used to the Teeth, when

they stand unnaturally, either too high, or too far forth.

XIX. 3. By Sawing. It is done with a Saw in a mortified Part, of which we shall speak when we come to Amputation.