Of Medicine, in Eight Books

by Aulus Cornelius Celsus

When the holes are made, the intermediate spaces must be cut out in the same manner, but with much more circumspection; lest the angle of the chisel chance to wound the same membrane; till a passage be made, through which the instrument to protect the membrane may be introduced. The Greeks call it meningo-phylax[ IA ]. It is a copper plate, firm, bent a little upward towards the end, and externally smooth: which being introduced in such a manner, that its external surface be next the brain, is put under that part, which is to be separated by the chisel; and if it receives its angles, it stops its progress; and upon this account the physician repeats his strokes upon the chisel both more boldly, and more safely, till the bone being cut out all round is raised by this plate, and may be taken away without any hurt to the brain. When the whole bone is taken out, the edges must be scraped round and smoothed, and if any dust has fallen upon the membrane, it must be gathered up. When the superior part is taken away, and the inferior left, not only the edges, but the whole bone must be smoothed, that the skin may afterwards generate upon it without being hurt, which growing upon a rough bone, does not immediately become sound, but produces new pains.

The steps to be taken after the brain is uncovered, I shall mention, when I come to fractured bones. If any base is preserved, medicines not greasy, that are calculated for recent wounds, must be applied, and over them must be laid sordid wool moistened with oil and vinegar. In process of time flesh grows from the bone itself, which fills up the cavity made by the operation. And when any bone is cauterized, it separates from the sound part, and granulations sprout up between the sound and mortified part, which expel what has separated. And this, because it is a thin and small lamina, by the Greeks is called lepis[ IB ], that is, a scale.

It may happen too, that from a blow, a bone may be neither fissured, nor broke through, but the surface of it only contused, and rendered rough. When this occurs, it is sufficient to scrape and smooth it. Though these methods are most commonly practised in the head, yet they are common to the other bones too; so that wherever the like case shall occur, the same remedy must be used. But as they are fractured, fissured, perforated, and contused, they require some particular methods of cure in each kind, and in most of them, some general ones also. Of these I shall proceed to treat, beginning with the head.

CHAP. IV. OF FRACTURES OF THE SKULL.

When a blow has been received upon the skull, we must immediately enquire, whether the person has vomited bile; whether he have lost his sight, or his speech; whether blood has issued by his nostrils, or ears; whether he has immediately fallen down; whether he has lain insensible, as if asleep: for these do not happen without a fracture of the bone. And when they occur, we may be assured, that an operation is necessary, but of uncertain success. If besides, a torpor has come on; if he is delirious, if either a palsy, or a convulsion has followed, it is probable that the membrane of the brane too is wounded; and of such patients there is still less hope. But if none of these have ensued, and it may be doubted, whether the bone be fractured, it is first to be considered, whether the blow was given by a stone or a stick, or iron, or any other weapon, and whether the instrument was smooth, or rough, small or large, whether struck with force, or more lightly; because the more gentle the stroke was, so much the more easily we may suppose the bone to have resisted it. But it is best to examine that by a more certain mark. Therefore a probe ought to be introduced where the wound is, neither too small nor sharp, lest if it should light upon any of the natural sinuses, it mislead us into an opinion of a fracture, where there is none; and not too thick, lest small fissures escape it. When the probe comes to the bone, if nothing but what is smooth and slippery occur, one may judge it to be sound; if there is an asperity, especially where there are no sutures, that is an evidence the bone is fractured.

Hippocrates has recorded, that he was himself deceived by the sutures. This is the custom of great men, who have a just consciousness of their own superior abilities: for little minds, because they are deficient in every thing, never allow themselves to be deficient in any. An ingenuous confession of an error is worthy of a great genius, who will have enough besides to entitle him to esteem; and it is especially laudable in a practical art, which is handed down to posterity for their benefit; that they may not be deceived in the same way another was deceived before them. A regard to the memory of a professor, in other respects so great a man, led us into this digression.

Now a suture may deceive for this reason, because it is equal in asperity to the other; so that though there be a fissure, one may readily take it for a suture, in a place, where it is likely one lies below. Therefore it is not fit to be thus deceived; but the safest method is to lay bare the bone: for, as I observed before, the place of the sutures is not certain; and the same part may both have this natural junction, and be fissured by a blow, or may have some fissure near it. Nay sometimes, when the blow has been violent, though nothing be found by the probe, yet it is better to open it. And if even then the fissure is not manifest, writing ink must be drawn over the bone, and then scraped off with a chisel, for if there be any fissure it retains the blackness.

Sometimes it even happens, that the blow has been given on one side, and the bone fissured on the other. For that reason, if upon receiving a violent blow, bad symptoms have followed, and no fissure be found in that part, where the skin is lacerated; it is not improper to consider, whether any part on the opposite side be softer, and swelled; and to open that; for there a fissure in the bone will be found. Nor is it very troublesome to heal the skin again, though nothing has been discovered by the incision. A fractured bone, unless help be seasonably administered, brings on violent inflammations, and is treated with more difficulty afterwards.

Rarely, but sometimes it happens, that the whole bone remains sound; but from the blow some internal vein in the membrane of the brain is broke, and discharges blood, which being coagulated there, raises violent pains, and deprives some people of their sight. But there is generally a pain in the part that covers it, and an incision being made in the skin there, the bone is found pale; and therefore this must also be cut out. Upon whatever account this operation is necessary, if the opening of the skin is too small, it must be enlarged, till all the injured part be in view. In this great care must be taken to leave upon the bone no part of that fine membrane that covers the skull below the skin; because when this is lacerated by the chisel, or perforators, it excites violent fevers with inflammations. Therefore it is better to separate it entirely from the bone. If the external wound be made by the blow, we cannot alter the form of it. If we are to make one, the best is that made by two transverse lines in the shape of the letter X, that afterwards the skin may be cut below, beginning at each of the prominent angles.

If blood is discharged in the time of doing this, it must be frequently restrained by a spunge dipped in vinegar, and taken up by lint applied upon it, and the head raised high. This accident is attended with no danger except among the muscles, which secure the temples; but even in that place there is no safer method.