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.
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
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
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
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.