De Medicina

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

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. 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 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

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 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, 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

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

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 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-

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-

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.