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. XV. Of an INCISION and PƲNCTƲRE of the SCƲLL.

I. THAT which the Greeks call, 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. and the Latins, Cranii Incisio; we in English call, An Incision or Cutting of the Scull: but when any piece of the Scull is wholly cut off, then the Greeks call it, 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. and the Latins, Cranii Excisio.

II. That which the Greeks call, 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. and the Latins, Cranii Punctura; we in English call, A Puncture of the Scull: but when the Weapon sticks so fast, that by pulling it forth, the Scull thereby seems to be pulled up, and to vault forth; the Greeks call it, 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. and the Latins, Cranii concameratio.

I. Of an Incision of the Scull.

III. An Incision is made by a cutting Instrument; wherein either a part of the Scull is raised up, but is yet fast to the other part: or, a mark of the Cut only remains in the Scull, according to the figure of the Instrument, which they call Sedes, or, the Seat; being the Seat of the Weapon: or, a part of the Scull is cut slopingly thro', and quite taken away.

IV. As to the Sedes, where the Print of the Weapon is only left behind in the Scull; the

Wound is to be dilated or opened, and the Skin and Flesh with the Pericranium is to be raised, and the Sedes or Seat of the Weapon is to be imme∣diately pared away with a Knife or Chizel; or it must be scraped with a Scraping-Instrument, and that 'till the whole Sedes or Incision is gone.

V. After the Sedes or Print of the Weapon is pared or scraped away, you must dress it with con∣venient Medicaments, such as we use in the Cure of a Fissure, or after the rasping of the Scull.

VI. If it passes thro' both Ta∣bles, and splints of Bone prick the Meninges; and way enough is made by the Weapon, for the evacuating of the Pus or Matter; no farther apertion is to be made, but the Wound is to be dressed, as after the application of the Trepan.

VII. But if either splinters of Bones do offend the Dura Mater, or the way out is too narrow for the coming forth of the Sanies or Pus; a farther opening of the Scull is to be made, with such Instru∣ments as you shall think most fit for the Operation.

VIII. But if the Sedes passes no farther than the first Table, then the Cranium is only to be smoothed with Raspatories; that the Pus or Matter may not settle in the Sedes, and so cause a deeper ca∣riosity; and the Wound is to be drest with Linimentum Arcaei, melted in a Spoon: in these Cases many times, if the Patient is of a good habit of Body, the Cranium casts off no Scales.

IX. If a part of the Scull is raised up by the Cutting, out yet is fast on the other parts; having dilated the Wound, see whether the Weapon has passed the first Table only, or the first and second, if the first only, the Bone may be rasped away; but if both, there will be a necessity of applying the Trepan, to make way for the Matter.

X. The lips of the Wound may be kept asunder with Pledgets, or Dossels of fine Tow dipt in whites of Eggs, which will also stop the flux of Blood: the Parts which are ad∣jacent are to be anointed with astringent Oils made hot, to prevent Inflammation, and con∣venient Ligature is to be ap∣plied, which is the Band-Cancer, with a thrice doubled linnen Cloth; that the wounded Parts may not be more hurt by the ambient Air, (which is an Enemy to the Wounds of the Head;) and that the Medicaments laid on, may be kept close, and not fall off.

XI. The following Figure repre∣sents the Band-Cancer, which for Wounds of the Head, is the best of all to contain them, and also the most useful and commodious: it is broad in the middle A, and both ways it has four ends; of which two begin from the Temples, and end on the hin∣der part of the Head; where they must be sewed, as E, E: two arise from the hinder part of the Head, and are bound together on the forepart of the Head, as B, B: two are turned behind the Ears, and fastned under the Chin, as C, C: and

two of them come before the Ears, and are fastned as the other also, under the Chin; as D, D.

[illustration] depiction of the band cancer, a bandage for the head

The Band Cancer

XII. The second day, let the Wound be drest; being cleansed of its Sanies, let some Astringent Pouder or dry Lint be laid upon the Bone, and let the lips of the Wound be drest with some Dige∣stive, which apply upon Lint; and and over that Emplastr. Album, or Diapalma, with a Hole cut in in it for the Pus to issue forth; over which Hole lay Linimentum Arcaei, with a Pledget of Cloth three times doubled: anoint the Parts adjacent with some Astrin∣gent Oil before-named, then bind it up with the Band-Cancer, and a good Rowler; and con∣tinue this course of Dressing, 'till a good and white sort of Pus, and not stinking, is pro∣duced.

XIII. If the Artist is careful, he will find, where the Bone is only rasped or scraped, that if the Ce∣phalick drying Pouders be strewed upon it, and dressed with dry Lent, it will be covered with Flesh the next day: they that will not endure Scraping or Rasping the Bone, (when it is altered) leave it to Nature for the Scaling of it: but such Men prolong the Cure.

XIV. The Wound being digested, you must daily apply Detersives, mixed with Digestves, until it is throughly cleansed; continuing the use of the Pledget of Cloth thrice doubled, with the Un∣ctions and Bandage.

XV. The Wound being cleansed, you must with Sarcotick Ointments, as Linimentum Arcaei, &c. laid upon Lint, to the lips; fill it up with Flesh, (and not use Oil of Roses, as some Ignorants do;) and over that Diapalma, or Em∣plastr. Album, malaxed with a little Oil; and then a Cloth thrice doubled, wet in Red-wine, or some Astringent Decoction, and prest out again.

XVI. The Wound being filled with Flesh, it must at last be covered with a Cicatrice; which is done either with dry Lint only, or else by applying Cera∣tum Diviaum, or such other like; renewing the Dressing 'till the Skin is produced.

XVII. When a part of the Scull is separated, so that the first Table is divided from the second, and sticks close to the Skin, you must first take away the Bone, and then cure the Wound.

XVIII. If a part of the whole Scull is divided, so that the Dura Mater is seen, you must reduce

the Incision, being first cleansed with Canary or S.V. or with them mixed equally together; and so keep it, either by stitch∣ing the Lips of the Wound, or rather by fit Bandage.

XIX. But a smooth Chopping away, or Cutting off a piece of the Skull, requires no Manual Operation; but it ought to be co∣vered with Flesh, by strewing on it some Cephalick astringent Pouder, &c. as a Skull newly scraped, or rasped with Rasps.

II. Of a PƲNCTƲRE of the SKƲLL.

XX. If the Puncture pierces not both Tables, (as it seldom does) it must be taken off with Pier∣cers, or the Trafine, which must be put just upon the middle.

XXI. But if it penetrates thro' both Tables, the Skull must be opened with the Trepan, setting the Pin of the Male-Trepan upon the Point or Puncture, and so turning it round till it make a print, upon which the Female may stand fast.

XXII. Now that these Opera∣tions may be performed quickly, safely, and pleasantly, the Cutis Musculosa and Pericranium must be separated from the Bone: And when the Trepan has done its work, the rest of the Cure must be compleated, as we have al∣ready taught in Chap. 12. Sect. 83. ad 104.

XXIII. In all Fractures, if they be so large, or well-condition∣ed, that you can thereby free the Brain, or Place, from Coagulated or Corrupted Blood, or from the prickings of the Splinters; these Operations will be needless.

XXIV. But if otherwise, there is a necessity, you must use great Care in applying the Instru∣ments; which ought to be done before the Patient is grown too weak, or the Cure of the Dis∣ease is become past hope.

XXV. It is also to be noted, that if the bare Bone lies open to the ambient Air but for two Hours, the Bone will be altered; but if it lies open longer, it will grow black: In these Cases, if the Weapon (whether sharp-edged, or poin∣ted) pierces not both Tables, or pierces only one, or the Su∣perficies of the first Table, you must then scrape or rasp off all round about, till the Colour is changed, or the Sedes or Pun∣cture is taken totally away; or till Blood comes forth of it, &c.

XXVI. If there is a Concame∣ratio, or vaulting out of the Skull, made by the plucking out of a poin∣ted Weapon forcibly, whereby an empty space or vacuity is left be∣neath, and the upper Table is se∣parated from the lower; you have no more to do, but (dilating the Wound by Incision) to rasp or smooth the Skull, and then to heal up the Wound ac∣cording to the Method before laid down.

XXVII. But if it passes thro' the second Table, you must open the Skull in the most depending Part with the Trepan, to make way for the issuing forth of the Sanies or Pus, which of necessity must be lodged in the void space, if the hole the Weapon has made is

large enough to give a passage for the same.

XXVIII. And if any ruggedness or pointed Splinters prick the Dura Mater, the whole Fracture is to be removed, compassing it with a large head of a Trepan; after which the Wound is to be Cured, as we have formerly taught.

III. Of an Incision or Puncture of the Skull, under the Temporal Muscle.

XXIX. This is always with a Wound; and the Incision is either transverse, or according to the length of the Muscle: If it is a Puncture, or a transverse Inci∣sion, it will be of dangerous Consequence, as we have alrea∣dy proved, and for the most part, Mortal.

XXX. If the Wound is made longways, it is to be dilated by Dosils or Sponges; and if the Fra∣cture is a Cleft, it is to be remo∣ved by Rasps, or some scraping Tool: But if it is a great Fra∣cture, in which the points of the shivers do prick the Membranes, or the depression of the Crani∣um does press them down; then a triangular Incision is to be made, a little above the Fra∣cture, avoiding the Temporal Muscle.

XXXI. Which done, the Mo∣diolus or Trepan is to be applied: The Skull being opened, the Splinters which are perfectly se∣parated from the sound part of the Skull, are to be taken away; and the remainder which are not wholly separated, are to be reduced (if possible) to their true places.

XXXII. And as often as the Patient is drest, you are to cause him to stoop down his Head, and (stopping his Mouth and Nose) to cause him to force his Breath strongly, by which means the Sanies will be the better forced out of the Wound.

XXXIII. This being done, you must make some mundifying. In∣jection of red Wine, clarified juice of Smallage, and Honey of Roses strained, or with other things as you shall see most fit, to wash out all the Sanies, Pus, or other foulnesses, which other∣wise would necessarity lodge there.

XXXIV. And tho' Pareaens, lib. 9. cap. 19.) advised to keep a leaden Pipe in the Wound, yet this by reason of its hardness and solidity, would not dilate the Se∣ction, but cause pain; I should rather advise you to compressed or prepared pieces of Sponge, which is by much the better.

XXXV. For this as it is soft, it cannot hurt; and as it is po∣rous, so it will dilate it self, and suck up the Impurities; and with∣al, it will dilate the Wound, and keep, it sufficiently open, till all the Splinters of the Cra∣nium are fully come forth, after which the Wound is to be healed up, as other Wounds of the Head and Skull.