On Injuries of the Head (21)

With regard to trepanning, when there is a necessity for it, the following particulars should be known. If you have had the management of the case from the first, you must not at once saw the bone down to the meninx; for it is not proper that the membrane should be laid bare and exposed to injuries for a length of time, as in the end it may become fungous. And there is another danger if you saw the bone down to the meninx and remove it at once, lest in the act of sawing you should wound the meninx. But in trepanning, when only a very little of the bone remains to be sawed through, and the bone can be moved,

you must desist from sawing, and leave the bone to fall out of itself.[*] For to a bone not sawed through, and where a portion is left of the sawing, no mischief can happen; for the portion now left is sufficiently thin. In other respects you must conduct the treatment as may appear suitable to the wound. And in trepanning you must frequently remove the trepan, on account of the heat in the bone, and plunge it in cold water. For the trepan being heated by running round, and heating and drying the bone, burns it and makes a larger piece of bone around the sawing to drop off, than would otherwise do. And if you wish to saw at once down to the membrane, and then remove the bone, you must also, in like manner, frequently take out the trepan and dip it in cold water. But if you have not charge of the treatment from the first, but undertake it from another after a time, you must saw the bone at once down to the meninx with a serrated trepan, and in doing so must frequently take out the trepan and examine with a sound (specillum), and otherwise along the tract of the instrument. For the bone is much sooner sawn through, provided there be matter below it and in it, and it often happens that the bone is more superficial, especially if the wound is situated in that part of the head where the bone is rather thinner than in other parts. But you must take care where you apply the trepan, and see that you do so only where it appears to be particularly thick, and having fixed the instrument there, that you frequently make examinations and endeavor by moving the bone to bring it up. Having removed it, you must apply the other suitable remedies to the wound. And if, when you have the management of the treatment from the first, you wish to saw through the bone at once, and remove it from the membrane, you must, in like manner, examine the tract of the instrument frequently with the sound, and see that it is fixed on the thickest part of the bone, and endeavor to remove the bone by moving it about. But if you use a perforator (trepan?), you must not penetrate to the membrane, if you operate on a case which you have had the charge of from the first, but must leave a thin scale of bone, as described in the process of sawing.