De Medicina

Celsus, Aulus Cornelius

Celsus, Aulus Cornelius. De Medicina. Spencer, Walter George, translator. Cambridge, MA: Harvard University; London, England: W. Heinemann Ltd, 1935-1938.

31 We next pass from the foregoing subjects to the legs, and if varicose veins occur there, they are removed by a procedure which is not difficult. To this place I have put off also the treatment of the small veins which cause trouble in the head, also of varicose veins on the abdomen, because it is all the same. Any vein therefore which is troublesome may be shrivelled up by cauterizing or cut out by surgery. If a vein is straight, or though crooked is yet not twisted, and if of moderate size, it is better cauterized. This is the method of cauterization: the overlying skin is incised, then the exposed vein is pressed upon moderately with a fine, blunt, hot cautery iron, avoiding a burn of the margins of the incision, which can easily be done by retracting them with hooks. This step is repeated throughout

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the length of the vein, generally at intervals of four fingers' breadth, after which a dressing is put on to heal up the burns. But excision is done in the following way: the skin is similarly incised over the vein, and the margins held apart by hooks; with a scalpel the vein is separated from surrounding tissue, avoiding a cut into the vein itself; underneath the vein is passed a blunt hook; the same procedure is repeated at the intervals noted above throughout the course of the vein which is easily traced by pulling on the hook. When the same thing has been done wherever there are swellings, at one place the vein is drawn forward by the hook and cut away; then, where the next hook is, the vein is drawn forwards and again cut away. After the leg has thus been freed throughout from the swellings the margins of the incisions are brought together and an agglutinating plaster put on over them.

32 But if the fingers, either before birth or later on account of ulceration of their adjacent surfaces, adhere together, they are separated by the knife; after that each finger is separately enclosed in a plaster without grease, and so each heals separately. If after ulceration of a finger, a badly formed scar has made it crooked, in the first place a poultice is tried, and if this is of no avail, which is generally the case with old scars and tendon injuries, we must see whether the trouble is in the tendon, or in the skin only. If it is in the tendon, it should not be touched, for the condition is incurable; if in the skin, the whole scar should be cut out, which had generally become hard and so did not allow the finger to be extended. When it had been thus straightened a new scar must be allowed to form there.

33 When gangrene has developed between the nails and in the armpits or groins, and if medicaments have failed to cure it, the limb, as I have stated elsewhere, must be amputated. But even that involves very great risk; for patients often die under the operation, either from loss of blood or syncope. It does not matter, however, whether the remedy is safe enough, since it is the only

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one. Therefore, between the sound and the diseased part, the flesh is to be cut through with a scalpel down to the bone, but this must not be done actually over a joint, and it is better that some of the sound part should be cut away than that any of the diseased part should be left behind. When the bone is reached, the sound flesh is drawn back from the bone and undercut from around it, so that in that part also some bone is bared; the bone is next to be cut through with a small saw as near as possible to the sound flesh which still adheres to it; next the face of the bone, which the saw has roughened, is smoothed down, and the skin drawn over it; this must be sufficiently loosened in an operation of this sort to cover the bone all over as completely as possible. The part where the skin has not been brought over is to be covered with lint; and over that a sponge soaked in vinegar is to be bandaged on. The remaining treatment is that prescribed for wounds in which suppuration is to be brought about.

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1 The remaining part of my work relates to the bones; and to make this more easily understood, I will begin by pointing out their positions and shapes.

First then comes the skull, concave internally, convex externally, on both aspects smooth, where it covers the cerebral membrane as well as where it is covered by the skin bearing hair; and it is in one layer from the back of the head to the temples, in two layers from the forehead to the vertex. Its bones are hard externally, but the inner parts which connect them together are softer, and between these run large blood-vessels which probably supply their nutrition. It is rare for the skull to be solid without sutures; in hot countries, however, this is more easily found; and that kind of head is the firmest and safest from headaches. As for the rest, the fewer the sutures, the better for the heads; and there is no certainty as to the number, or even as to the position of the sutures. Generally, however, there are two above the ears separating the temples from the upper part of the head: a third stretches to the ears across the vertex and separates the occiput from the top of the head. A fourth runs likewise from the vertex over the middle of the head

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to the forehead, sometimes ending at the hairy margin, sometimes dividing the forehead itself and ending between the eyebrows. Most of these are dovetailed, but those which cross over above the ears are bevelled off a little all along their margin so that the lower bones smoothly overlap the upper. Now the thickest bone in the head is behind the ear, where hair does not grow, probably on that very account. Under the muscles covering the temples is situated the middle bone which slopes outwards. But the face has the largest suture; it begins at one temple, passes across the middle of the orbits and nose to the other temple. From this suture two short sutures are directed downwards from the inner corners of the eyes; and the cheeks at their upper parts also have transverse sutures. From the middle of the nostrils or of the gums of the upper teeth, one suture runs back through the middle of the palate, another cuts the same palate transversely. These are the sutures found in most skulls.

Now the largest passages leading into the head are those of the eyes, next the nostrils, then those of the ears. Those of the eyes lead direct and without branching into the brain. The two nasal passages are separated by an intermediate bone. These begin at the eyebrows and eye-corners, and their structure is for almost a third part bony, then changes into cartilage, and the nearer they get to the mouth the more soft and fleshy their structure becomes. Now these passages are single between the highest and lowest part of the nostrils, but there they each break up into two branches, one set from the nostrils to the throat for expiration and inspiration,

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the other leading to the brain and split up in its last part into numerous small channels through which we get our sense of smell. In the ear the passage is also at first straight and single, but as it goes further becomes tortuous. And close to the brain this too is divided into numerous fine passages which give the faculty of hearing. Adjacent to the passages there are two little pits, as it were, above which ends the bones which stretches across from the cheek, supported by deeper-seated bones: it may be called the yoke, from the same resemblance which led the Greeks to call it zygodes. But the lower jaw is a soft bone and a single one, of which the chin forms the middle and lowest portion, whence it is continued on the two sides to the temples; and it alone is movable, for the cheek-bones with all that bone which produces the upper teeth are immobile. Now the ends of the lower jaw itself form, as it were, two horns. One process broader below tapers to its tip, and as it passes higher, goes under the zygoma, and is fastened to the temporal muscles above it. The other is shorter and more rounded off, and in that pit which is adjacent to the auditory passages, it is set in a sort of hinge, and as it bends there forwards backwards supplies the power of movement to the lower jaw.

The teeth are harder than bone, some are fixed in the lower jaw, some in the cheek-bones. Of the teeth, the four in front are named by the Greeks tomis because they cut. These are flanked at each side by four canine teeth. Behind these on either side is generally a set of four molars, except in those who

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have five one tooth on each side coming through later. There are some in whom the four last, which generally come through late, do not make their appearance. Of these teeth the front ones are fixed by single roots, the molars at least by two, sometimes even by three or four; and generally the longer root produces the shorter teeth; the straight tooth has a straight root; a crooked tooth a crooked root. From the same root in children a new tooth grows which general pushes out the former one, but sometimes shows itself behind or in front of it.

Now the spine is the support of the head. It is composed of twenty-four vertebrae, seven in the neck, twelve belonging to the ribs; the remaining five are below the ribs. The vertebrae are bones rounded off and short; from each side they thrust out a transverse process; they are perforated in the middle where the spinal marrow which is connected with the brain passes downwards, and at the sides also through the two transverse processes they are traversed by fine channels, through which little membranes pass down resembling the cerebral membrane; with the exception of the three highest all the vertebrae have slight depressions in their articular processes on the upper side, on the lower side other articular processes grow downwards. The highest vertebra is therefore the immediate support of the head, receiving its small processes into two depressions, and this enables the head to move up and down. The second vertebra is made irregular by a protuberance and is attached to the lower side of the one above. To secure the rotation of the head the top of it ends in a narrower round process, so that the first vertebra

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encircling the top of this allows the head to turn sideways as well. After the same fashion the third vertebra supports the second, hence there is easy movement in the neck. And the neck could not even hold up the head were it not supported on each side by straight and powerful sinews which the Greeks call te/nontej; since whenever the head bends one of the sinews is always tense, and does not allow what is above to slip too far over. From the third vertebra in turn grow little protuberances which are inserted into the vertebra below; the remaining vertebrae are fastened into the ones below them by processes directed downwards and support the ones above them in the depression which they have on either side, and they are held together by many ligaments and cartilages. Thus by bending once in the required direction and avoiding moving in other directions man stands upright, or bends somewhat, to do anything that is required.

Below the neck the highest rib is placed on a level with the shoulders; after that there are six lower ribs, reaching as far as the bottom of the thorax; the ribs, which in their first part are rounded and end in small heads, as it were, are lightly fixed to the transverse processes of the vertebrae, which themselves have slight depressions; then the ribs flatten out and after curving outwards gradually degenerate into cartilage, and here, after again bending slightly inwards, they become united to the breast-bone. This, a strong and hard bone, begins below the throat, is lunated on each side, and, when it becomes itself softened into cartilage, is bounded by the praecordia. Below the upper ribs, there are five called by the Greeks nothae; they are short, thinner, and after changing gradually into

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cartilage, they are embedded in the highest part of the abdomen. The lowest of these consists for the most part only of cartilage. Again, from the neck two wide bones extend to the shoulders on each side; we call them scutula operta, the Greeks omoplatae. These bones are curved at their highest point, and below these they are triangular, and become gradually wider as they approach the spine. As they become wider, they become blunter. And they too at the lowest part soften into cartilage at the back and float, as it were, since they are unconnected with any other bone except at the top, but there they held in place by very strong muscles and sinews. Now at the level of the first rib, and a little behind its middle, a bone grows out which at first is slight but as it comes nearer the broad bone of the shoulder-blades becomes thicker and broader, and curves slightly outwards; and this at its other upper end is enlarged somewhat to support the root of the neck. But this bone itself is curved, and must not be reckoned among the hardest or most solid, and it lies with one head fixed as just stated, the other in a small depression of the breast-bone; it moves a little with the movement of the arm, and is connected with the flat bone of the shoulder-blades by sinews and cartilage.

From this point begins the humerus, which at both ends is swollen out, and is there soft, without marrow and cartilaginous; in the middle cylindrical, hard, contain in marrow; and slightly curved both forwards and outwards. Now its front part is that on the side of the chest, its back, that on the side of the shoulder-blades; its inner part that which faces the

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side, its outer away from the side. It will be clear in later chapters that this applies to all joints. Now the upper head of the humerus is more rounded than any other bone hitherto described and is inserted by a small excrescence into the top of the wide bone of the shoulder-blades, and the greater part of it is held fast by sinews outside its socket.

The humerus at its lower end has two processes, between which the bone is hollowed out even more than at its extremities. This furnishes a seat for the forearm, which consists of two bones. The radius, which the Greeks call cercis, is the uppermost and shorter; at its beginning it is thinner, with a round and slightly hollowed head which receives a small protuberance of the humerus; and it is kept in place there by sinews and cartilage. The ulna is further back and longer and at first larger, and at its upper extremity is inserted by two outstanding prominences into the hollow of the humerus, which, as I said above, is between the two processes. At their upper ends the two bones of the forearm are bound together, then they gradually separate, to come together again at the wrist, but with an alteration in size; since there the radius is the larger whilst the ulna is quite small. Further, the radius as it enlarges into its cartilaginous extremity is hollowed out at its tip. The ulna is rounded at the extremity, and projects a little at one part. And, to avoid repetition, it should not be overlooked that most bones turn into cartilage at their ends, and that all joints are bounded by it, for movement would be impossible unless apposition were smooth, nor could they be united with flesh and sinews unless some such intermediary material formed the connection.

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Turning to the hand, the first part of the palm consists of many minute bones of which the number is uncertain, but all are oblong and triangular, and are connected together on some plan since the upper angle of one alternates with the base of another; therefore they appear like one bone which is slightly concave. Now two small bones project from the hand and are fitted into the hollow of the radius; and at the other end five straight bones directed towards the fingers complete the palm; from these spring the fingers themselves, each composed of three bones; and all are similarly formed. A lower bone is hollowed out at its top to admit a small protuberance from an upper bone, and sinews keep them in place; from them grow nails which become hard, and thus these adhere by their roots to flesh rather than to bone.

And such are the arrangements for the upper limbs. Now the bottom of the spine is fixed between the bone of the hips, which lies crosswise and is very strong and so protects the womb, bladder and rectum; and the bone bulges out externally, is bent up towards the spin, and on the sides that is, the hips proper, it has rounded hollows; and from these start the bone they call the comb, situated crosswise above the intestines below the pubes, and this supports the belly; in men the bone is straight, in women more curved outwards so as not to hinder parturition.

Next in order are the thigh-bones, the heads of which are even more globular than those of the arm-bones, although those are the most globular of the other bones; below there are two processes, one directed forward, the other backward; after this the bones are hard and marrowy and convex on the outer

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side, and they are again enlarged at their lower ends also. The upper ends are inserted into hollows of the hip-bones, as the arm-bones into the shoulder-bones; then these tend gently downwards and inwards in order that they may support the upper parts of the body more evenly. But the heads at the lower end have a hollow in between, that the leg-bones may be more easily fixed into them. Their juncture is covered by a small, soft, cartilaginous bone, called the knee-cap. This bone, which floats freely and is not attached to any other bone, but held in place by flesh and sinews, is turned slightly towards the thigh-bone and protects the joint in all movements of the legs.

The leg itself is made up of two bones; for as the thigh-bone is throughout similar to the humerus, so is the leg like the forearm, hence the form and appearance of the one can be learnt from the other: and what holds good for the bones holds also for the soft parts. One bone lies outside, and this too itself is called the calf. It is the shorter, and is smaller in its upper part, but swells out just at the ankles. The other is placed more in front and is named tibia; it is the longer, and is larger at the upper end, and it alone joins with the lower head of the thigh-bone, as the ulna does with the humerus. These two bones, moreover, are joined together at the lower and upper ends, but in the middle as in the forearm they are separated. The leg below is received by the transverse bone of the ankles, which itself is set upon the heel-bone; the heel-bone is hollowed out in one part, and has excrescences at another part, so that it receives the excrescences of the ankle and is received itself into the hollow of the ankle. The

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heel-bone is without marrow, is hard, and projects somewhat backwards where it presents a rounded outline. The other bones of feet are constructed in a similar way to the bones of the hand; the sole corresponds to the palm, digits to digits, nails to nails.

2 Now when any bone has been injured, it either becomes diseased or splits or is broken or perforated or crushed or displaced.

A diseased bone generally first becomes fatty, next either blackened or rotten; and this occurs in cases of severe ulceration or fistula, when these have become chronic or even gangrenous. And it is necessary in the first place to expose the diseased bone by cutting out the ulcer, and if the bone disease extends beyond the margins of the ulcer to cut away the flesh until sound bone is exposed all round. Then if the diseased bone appears merely fatty, it is enough to apply a cautery once or twice until a scale of Boeotian comes away; or to scrape it away until there is bleeding, which is a sign of sound bone; for diseased bone is necessarily dry. The same is also to be done for diseased cartilage; it too must be scraped away with a scalpel until what remains is sound. Then, whether bone or cartilage has been scraped, finely powdered soda must be dusted on; and nothing different is to be done when the surface of the bone is black or carious, except that the treatment by cautery or scraping must be continued for a longer time. In these cases if the surgeon scrapes he should press boldly upon the instrument that he may effect more and finish sooner. The end is when white or hard bone is reached. White bone instead of black, or hard

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bone instead of carious clearly indicates the end of the diseased part. I have already stated that sound bone also bleeds to some extent.

But if in either case it is doubtful how deep the disease has reached, in the case of carious bone, this is readily ascertained. A fine probe is introduced into the hole, and according as it enters to a less or greater extent, it shows either that the caries is superficial or that it has penetrated more deeply, With black bone it is possible to form some opinion also from the pain and fever; when these are moderate in degree, the disease cannot have penetrated deeply. This becomes more obvious, however, when a trepan is used; for the limit of disease is reached when the bone dust ceases to be black.

Therefore, if caries has penetrated deeply, by means of the trepan holes are bored in the bone at frequent intervals, equal in depth to the extent of the disease; next cautery points are passed into these holes, until the bone becomes entirely dry. For after such applications, simultaneously the diseased part separates off from the bone underneath, and the cavity will make flesh, and no humour or very little will be subsequently discharged.

If on the other hand the disease, whether blackness or caries, has extended to the other side of the bone as well, excision is required; and the same can be done when caries has penetrated right through a bone. But whatever is wholly diseased is to be wholly removed; if the lower part is sound, only that which is corrupt should be excised. Further, if there is caries of the skull or breast-bone or rib, the cautery is useless, and excision is necessary. Nor are we to listen to those who await the third

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day after the bone has been laid bare before excising; for all cases are treated more safely before the inflammatory reaction. Therefore, whenever possible at the same sitting, the skin is to be incised, and the bone exposed, and freed from a that is diseased. And much the most dangerous case is in the breast-bone, for even if the operation has been successful, complete healing scarcely ever results.

3 Now bone is excised in two ways; if the damaged part is very small, with the modiolus, which the Greeks call xoineiki/j; if more extensive by means of trepans. I will describe the use of both. The modiolus is a hollow cylindrical iron instrument with its lower edges serrated; in the middle of which is fixed a pin which is itself surrounded by an inner disc. The trepans are of two kinds; one like that used by smiths, the other longer in the blade, which begins in a sharp point, suddenly becomes larger, and again towards the other end becomes even smaller than just above the point. When the disease is so limited that the modiolus can include it, this is more serviceable; and if the bone is carious, the central pin is inserted into the hole; if there is black bone, a small pit is made with the angle of a chisel for the reception of the pin, so that, the pin being fixed, the modiolus when rotated cannot slip; it is then rotated like a trepan by means of a strap. The pressure must be such that it both bores and rotates; for if pressed lightly it makes little advance, if heavily it does not rotate. It is a good plan to drop in a little rose oil or milk, so that it may rotate more smoothly; but if too much is used the keenness of

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the instrument is blunted. When a way has been cut by the modiolus, the central pin is taken out, and the modiolus worked by itself; then, when the bone dust shows that underlying bone is sound, the modiolus is laid aside. But if disease is too extensive for the modiolus to cover, the operation must be carried out by the trepan. With this a hole is made exactly at the margin of the diseased and sound bone, then not very far off a second, and a third, until the whole area to be excised is ringed round by these holes; and here also the bone dust shows how deep the trepan is to go. Next the excising chisel is driven through from one hole to the other by striking it with a mallet, and cuts out the intervening bone, and so a ring is made like the smaller one cut by the modiolus. And in whichever way the circle has been made, the same excising chisel should cut away from the corrupted bone every scale-like layer until sound bone is left. Black bone hardly ever penetrates the whole thickness of the bone, but caries sometimes does so, and especially when the cranium is diseased. A test of this is also made by means of the probe, which when inserted into a cavity which has solid bone underneath finds some resistance because of this and is wet when it comes up. If it finds a clear way, as it goes deeper between bone and membrane, it encounters no resistance and comes up dry; not because there is no harmful sanies within, but because this is spread over a wider area. If bone is diseased right through, whether it be black bone exposed by the trepan, or caries discovered by a probe, the use of the modiolus is generally out of place, because what goes down so deep must be more widely opened up.
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Then the trepan which I described second is to be used; and in order that it may not get too hot, it should be dipped repeatedly in cold water. But particular care must be taken when we have bored half through a bone consisting of a single layer, or through the upper layer of a bone of two layers; in the former the actual distance bored, in the latter the appearance of blood is the indication. Therefore the strap is then worked more gently and the left hand held up and moved away more often, and the depth of the borehole is to be examined in order that we may perceive just when the bone is being broken through anywhere, and not run the risk of injuring the cerebral membrane by the point; which causes severe inflammation with danger of death. When boreholes have been made, the intervening partitions are to be excised in the same way but much more carefully, lest the corner of the chisel injure the aforesaid membrane; until a sufficient opening has been made to insert a guard of the membrane which the Greeks call meningophylax. This consists of a plate of bronze, its end slightly concave, smooth on the outer side; this is so inserted that the smooth side is next the brain, and is gradually pushed in under the part where the bone is being cut through by the chisel; and if it is knocked by the corner of the chisel it stops the chisel going further in; and so the surgeon goes on striking the chisel with the mallet more boldly and more safely, until the bone, having been divided all round, is lifted by the same plate, and can be removed without any injury to the brain. When all this bone has been removed, the margins of the opening must be filed down
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smooth, and if any bone dust is sticking to the membrane it is to be removed. When the outer table has been removed, and the inner table left, it is not only the margins but also all the bone which is to be smoothed down, in order that skin may grow over it subsequently without harm; for when it grows over rough bone there is never sound healing, but it causes new pains. What is to be done when the bain is exposed, I will describe when I come to fractures. If some of the inner table has been preserved, medicaments which are not greasy, such as are fitted for recent wounds, are to be applied, and over that, unscoured wool soaked in oil and vinegar. In course of time flesh grows up from the bone and fills up the hollow made by the surgery. Also if any bone has been cauterized it separates from the healthy part, and between the sound and dead bone granulations form to throw off what has separated; and this is usually a thin and small splinter, which the Greeks call a scale.

It may possibly even happen as the result of an injury, that bone, although neither fissured nor fractured, yet has its surface indented and roughened; when this happens scraping and smoothing suffice. These conditions, although mostly occurring in the head, are found also in the other bones, so that whenever the same thing happens the same procedure is to be followed. But for bones which are fractured, fissured, perforated or crushed, some special treatment is required, suited for particular cases, and some general measures which apply to the majority; of these I will proceed to treat, beginning with the said cranium.

4 Therefore after a blow on the head first we

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must enquire whether the patient has had bilious vomiting, whether there has been obscurity of vision, whether he has become speechless, whether he has had bleeding from the nose or ears, whether he fell to the ground, whether he has lain senseless as if asleep; for such signs do not occur unless with fractured bone; and when they are present, we must recognize that treatment is necessary but difficult. If in addition there is also stupor, if the mind wanders, if either paralysis or spasm has followed, it is probable that the cerebral membrane has also been lacerated; and then there is little hope. But if none of these signs follows the injury, it is not even certain whether the bone is broken: and the first thing then to consider is whether he was struck by a stone or club or sword or other such weapon, and whether such a weapon was blunt or pointed, medium or heavy, used with much or little force; for the lighter the blow, the more easily we may conclude that the bone has resisted it. But the best plan is to make certain by exploration. Accordingly a probe should be introduced into the wound; it should be neither very fine nor pointed, lest it enter one of the natural sutures and give rise to a false belief in a fracture of bone; neither should it be too thick lest small fissures be missed. When the probe comes into contact with the bone, if nothing but what is smooth and slippery is met with, it can be seen that the bone is intact; if any roughness is met with, at least where there are no sutures, it is a sign that the bone is fractured. Hippocrates, with great men's love of truth in great matters, has described how he had
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been deceived by sutures. For shallow minds, because they have nothing, never belittle themselves; such a sincere confession of the truth befits a great mind which will still have many titles to greatness, and especially in performing the task of handing down knowledge for the advantage of posterity, that no one else may be deceived again by what has deceived him. But my regard for the memory of a great teacher has somehow led me into this digression. Now a suture may possibly deceive just because it is rough too; so that although there is really a fissure, yet we may take it to be a suture, where it is likely that there is one. Therefore we must not be deceived just by this; the safest way is to lay bare the bone. For as I have stated above, sutures are not always in the same position, and a natural union of bone and a fissure from injury may coincide, or the fissure may be close by. Therefore sometimes when the blow was severe, although nothing is detected by the probe, it is still best to open the place up. And if even then no fissure is visible, ink is to be applied over the bone, then it is to be scraped with a chisel; for a fissure will retain the blackness. It may even happen that the blow may have been upon one part of the head, and fracture at another. Thus if anyone has been heavily struck and bad signs have followed, and no fissure has been found in the part where the scalp has been wounded, it is worth while to examine whether some other part is softer and swollen, and to lay it open; then perhaps fissured bone may be found there. Even if it be uselessly incised, the scalp heals without much trouble. A fractured bone unless it is treated causes severe inflammations,
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and is treated afterwards with greater difficulty. Rarely, but now and then, it happens, however, that whilst the bone remains whole and sound, yet within the skull a blood-vessel in the cerebral membrane has been ruptured by the blow and some blood has escaped, and this having formed a clot, causes great pains, or sometimes obscures vision. But generally the pain is directly over the clot, and when the scalp at that point is incised, the bone is found to be pallid; if so, that bone also is to be cut out.

But for whatever cause this treatment is necessary, if the scalp has not been laid open sufficiently, it must be incised more widely until the injury is well in view. In doing so we must see that none of the fine inner membrane covering the skull, under the scalp, remains over the bone; for whenever this is lacerated by the chisel or trepan it causes severe fevers with inflammations, and so it is better to raise it wholly off the bone. If there is a cut as part of the wound we must take it as it is; if we have to make it, the best incision is generally that which is formed by two lines in the shape of the letter X; next the scalp is raised by cutting under each of the little tongues. When doing this if bleeding takes place it must be checked by the application of a sponge saturated with vinegar from time to time, also it must be absorbed by swabs of dry lint and the head must be raised higher. There need be no anxiety unless it comes from among the muscles covering the temples; but there also this is the safest method of dealing with it.

In every case of a fissured or fractured bone, the older practitioners resorted at once to the instruments for cutting out the fragments. But it is much

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better first to try the plasters which are prepared for the cranium. One of these dissolved in vinegar is to be put upon the fissured or fractured bone by itself; next over this, a little overlapping the wound, lint steeped in the same, and over this unscoured wool sprinkled with vinegar; then the wound is bandaged and the dressing changed daily, and so treated up to the fifth day; on the sixth day also the wound is steamed by means of a sponge, then dressed as before. And if granulation begins, and the feverishness either subsides or lessens, and appetite returns, and there is sufficient sleep, we should persevere with the same applications. Next as time goes on, the plaster is to be softened by the addition of the cerate made with rose oil that it may cause the flesh to grow more readily; for by itself it has a repressant action. Under this treatment fissures are often filled up by some callus which forms a sort of scab in the bone; and if the fragments are more widely separated, any that are not in contact also become fastened together by the same callus, and this is a better covering for the brain than the flesh which grows up after the bone has been excised. But if under this first treatment fever becomes intensified and sleep short and disturbed by dreams, while the wound discharges and does not heal, and the glands in the neck on each side swell, and there is great pain, and in addition a growing aversion to food, then at length we must resort to surgery with the chisel.

A blow on the cranium involves two dangers; either a split bone or a depressed fracture. If the bone is split, the edges may remain in close contact, either because one margin overrides the other, or

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because they have become closely interlocked again. Hence it follows that humour collects on to the cerebral membrane but has no means of exit, and so irritates it, exciting severe inflammation. But when there is a depressed fracture, the bone presses on the cerebral membrane and sometimes also sharp points like needles from the fractured bone cause irritation. Cases like this require assistance, with as little loss of bone as possible. Therefore if one edge overlies the other, it is sufficient to cut away the overlying edge with a flat chisel; when this is removed a gap is left wide enough for treatment. But when the fractured edges have become interlocked, a hole should be made with a trepan at a finger's breadth to one side; and from this two cuts should be made with the chisel to the fissure, in the form of the letter V, with the apex at the hole and the base at the fissure; but if the fissure is a lone one, similar curs should be made from a second hole. And thus there is no concealed cavity in that bone, and a way out is given freely to all harmful material within. Even when the fractured bone is depressed, it need not all be excised. But whether completely broken off and separated from the rest, or still attached by a small portion to the skull around, the fragment should be separated by the chisel from the sound bone. Next, in the depressed fragment, close to the groove which we have just made, holes are to be bored as well; two when the damage is of small extent, three when larger, and the intervening partitions must be cut through. Next the chisel is to be so used on each side of the said groove, that a crescent-shaped gap is made with its convexity on the side of the fragment, and its horns directed
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towards the intact bone. Then if there are any detached fragments which can be easily removed, they are to be seized with forceps made for the purpose and particularly the pointed fragments which are irritating the membrane. If this cannot be done easily, the plate which I have suggested as a guard of this membrane is to be passed underneath in order that all pointed fragments which project inwards may be cut away over the plate, and any depressed bone is to be raised by means of the same plate. This method of treatment ensures that fragments still attached become consolidated; and detached fragments come away in course of time under the dressing without any pain; and by that treatment there is left a gap in the skull large enough for the extraction of matter; and the brain is better protected by leaving the bone than if it had been excised. After this, that membrane should be sprinkled with strong vinegar, in order that any bleeding from it may be checked, or any collection of clot which remains inside may be broken up. Then the same plaster, softened as described above, should be put on the membrane itself; and the rest of the dressing as before, ointment on the lint, and unscoured wool; the patient should be kept in a warm room; the wound dressed daily, even twice a day in summer.

But if the membrane swells up through inflammation, it is to be bathed with tepid rose oil; if it swells so as to project even above the level of the skull, well-ground lentils or crushed vine leaves, mixed either with fresh butter or goose-grease, will control it; and the neck should be anointed with liquid cerate containing iris oil. But if it shall ap-

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pear that the membrane is not clean, equal parts of its special medicament and of honey are to be mixed together and poured on, and to keep this in place one or two pads of lint must be put on, and over all linen upon which some of the medicament has been smeared. When the membrane is clean, a cerate to form flesh is to be added to the medicament and similarly applied.

As regards abstinence and the food and drink at first and later, the same course is to be adopted as I prescribed for wounds, and all the more because the danger is greater when this part is affected. And even when the time has come not only to sustain but also to build up the patient, still anything requiring mastication should be avoided; and also smoke and anything which provokes sneezing. But there is good hope when the membrane is movable and of normal colour, when the flesh growing up is a brit red, and when the jaw and neck move with ease. Bad signs are: the membrane immobile, black or livid or any other unwholesome colour; delirium, acrid vomiting, paralysis or spasm livid flesh, rigor of jaw and neck. As for other signs — sleep, appetite, fever, colour of the pus — the indications as to recovery or death are the same as in the case of other wounds. When things are going well, flesh grows up from the ma itself and from the bone as well if it is in two layers, so that the space between the bones becomes filled up; sometimes it even grows out above the skull. If this occurs copper scales are to be dusted on in order to repress and control it. Also applications to induce a scar must be laid on the flesh. And this is readily brought about everywhere except on the forehead a little above the eye-

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brows; for there it is almost impossible to avoid a lifelong wound which has to be kept covered by medicated lint. It should be the rule for all cases in which the skull has been fractured, that until the scar is firm, the patient should avoid sun, wind, frequent baths, and the free use of wine.