Chapter XXVI: Preface (4)

Diseases of the anus also, when they are not removed by medicines, require the assistance of the hand. Therefore, if any fissures, in that part, by long continuance, have become indurated, and are already callous, it is most proper to give a clyster; then to apply a hot spunge, in order to relax them, and bring them to the external part, when they are in view, to cut off each of them with a knife, and renew the ulcers; then to lay on soft lint, and over it honey spread upon a linen cloth; and to fill up the part with soft wool, and thus bind it up; on the next and following days, to dress with mild medicines, which I have elsewhere prescribed for the same disorders when recent; and in the first days to diet the patient with gruels, after that gradually to add to the food, but something of that kind, which I have directed in the same place. If at any time, from an inflammation, pus arises in them, as soon as that appears, an incision must be made to prevent the anus itself from suppurating. But we must not be in a hurry to do it before; for if it be cut while crude, the inflammation is much increased, and a greater quantity of pus is generated. In these wounds too, there is a necessity for mild food, and the same kind of medicines.

But the tubercles called condylomata, when they have grown hard, are cured in this manner. First of all, a clyster must be given. Then the tubercle being laid hold of by a vulsella, must be cut out near its roots. When this is done, the same course must be followed, that I prescribed after the preceding operation; only if there is any fungus, it must be kept under by copper scales.

The mouths of the hæmorrhoidal veins, discharging blood, are taken off thus. When there is a discharge of sanies besides blood, an acrid clyster must be administered, that the mouths of the veins may be pushed the farther outward; which causes all the vessels to appear like small heads. Then if a head be very little, and have a small base, it must be tied with a thread a little above the point, where it joins the anus; and a spunge squeezed out of hot water must be laid over it, till it grow livid; then above the knot it must be scarified either by the nail or the knife. If this is not done, violent pains ensue, and a difficulty in making water. If it be pretty big, and the base broad, it must be taken hold of with a small hook or two, and an incision made round the tumour, a little above the base; and neither any part of the head must be left, nor any thing taken off the anus: which a person may accomplish, if he neither draws the hooks too much nor too little. Where the incision has been made, a needle should be put in, and below that the head tied with a thread. If there be two or three of them, the inmost must be cured first; if more than that number, not all at once, lest there be(35) sore places all round the part at the same time. If there is a discharge of blood, it must be received in a spunge; then lint must be applied; the thighs, groin, and what lies contiguous to the ulcer, be anointed, and cerate laid over it, and the part filled with warm barley meal, and thus bound up. The day following, the patient ought to sit down in warm water, and be dressed with the same cataplasm. And twice in the day, both before and after the dressing, the ischia and thighs must be anointed with liquid cerate, and the patient kept in a warm place. After an interval of five or six days, the lint is to be taken out with a specillum oricularium; and if these heads have not dropped off at the same time, they must be pushed off by the finger. Afterwards, the ulcer must be brought to heal by mild medicines, such as I have prescribed before. The proper treatment, when the disease is cured, I have already mentioned elsewhere.

CHAP. XXXI.

OF VARICES IN THE LEGS.

From these disorders we go on to the legs. Varices in these are not difficult to remove. To this place I have deferred the cure of those small veins, which hurt in the head, as also the varices in the belly, because it is the same in them all. Therefore any vein that is troublesome, either is cauterized, and so decays, or is cut out. If it be straight, or though transverse, yet simple, it is better to cauterize it. If it be crooked, and as it were twisted into orbs, or several of them are involved within each other, it is more convenient to cut them out.

The method of cauterizing is this. An incision is made in the skin over it; then the vein being laid bare, is moderately pressed by a small and blunt iron instrument red hot: and we must avoid burning the lips of the wound itself, which it is easy to draw back with small hooks. This is repeated over the whole varix, at the distance of about four fingers breadth; and after that a medicine for healing burns is laid on.

But it is cut out in this manner. An incision being made in the same way in the skin over the vein, the lips are taken up with a small hook; and the vein is separated all round from the flesh by a knife, but in this great care is taken not to wound the vein itself; and a blunt hook is put under it; and generally, at the same distance mentioned before, in the same vein, the same operation is repeated. The course of it is easily discovered by extending it with the hook.

When this has been done, as far as the varices go, the vein, being brought forward in one part by the hook, is cut through, then where the next hook is, it is drawn up and pulled away, and is cut off there again. And in this manner the leg being entirely freed from the varices, the lips of the wounds are then brought together, and an agglutinating plaister is laid over them.

CHAP. XXXII.

OPERATIONS REQUIRED IN COHERING AND CROOKED FINGERS.

If the fingers, either from the birth, or by an ulceration in their opposite sides, have afterwards adhered together, they are separated by the knife; round each of them a plaister, not greasy, is put on, and thus they heal separately.

But if there has been an ulcer in a finger, and afterwards a cicatrix injudiciously brought on, has rendered it crooked; in the first place a malagma must be tried. If that does no good (which generally happens both in an old cicatrix, and where the tendons are hurt) then we ought to see whether the fault be in the tendon or the skin. If in the tendon, it ought not to be touched, for it is not curable: if in the skin, the whole cicatrix must be cut off, which being generally callous, prevents the fingers from being extended. Then being kept extended, it must be brought to cicatrize afresh.

CHAP. XXXIII.

OF THE OPERATION REQUIRED IN A GANGRENE.

I have elsewhere observed, that a gangrene comes about the nails, armpits or groin; and that if it does not yield to medicines, the member ought to be cut off.

But even this is attended with very great danger: for the patients often die in the operation, either by a hæmorrhage, or faintings. But in this, as well as other cases, it is not to be considered, whether the remedy is very safe, which is the only one we have. Between the sound and corrupted part then, an incision must be made with a knife in the flesh, as far as the bone. But this must not be done over a joint; and some of the sound part must rather be cut off, than any of the corrupt left. When we come to the bone, the sound flesh must be drawn back from it, and cut below round the bone, that some part of the bone may also be laid bare under it; then the bone must be cut off with a saw, as close as we can to the sound flesh, that still adheres to it; and then the fore part of the bone, that has been roughened with the saw, must be smoothed, and the skin brought over it; which in a cure of this kind ought to be lax, that it may cover the bone as much as possible all round. The part, which the skin does not reach, must be covered with lint, and above that a spunge squeezed out of vinegar must be tied on the place. The remaining part of the cure must be the same, as I have directed in wounds which are brought to digestion(36).

A. CORNELIUS CELSUS

OF

MEDICINE.

_BOOK VIII._

CHAP. I.

OF THE SITUATION AND FIGURE OF THE BONES OF THE HUMAN BODY.

It now remains, that I speak of what relates to the bones: for the easier understanding of which, I shall first describe their situations and forms. The first then is the skull, which is concave on the internal side, externally gibbous, and on each side smooth, both where it covers the membrane of the brain, and where itself is covered by the skin, from which the hair grows. In the occiput and temples it is simple; but double from the forehead to the vertex. And the bones of it in their external part are hard; on the inside, where they are connected with each other, softer. And veins are distributed between them, which probably supply them with nourishment.

Now the skull is rarely entire without sutures; but in hot countries it is more frequently found so. And such a head is strongest, and the most safe from pain; of others, the fewer sutures there are, so much the freer is the head from complaints; for their number is not certain, nor indeed their situation. However, for the most part two above the ears divide the temples from the upper part of the head; the third running to each side through the vertex, separates the occiput from the top of the head; the fourth goes from the vertex along the middle of the head to the forehead; and this ends in some at the point, to which the hair extends, in others between the eye-brows, dividing the forehead itself(1). The other sutures are exactly fitted to each other upon the same level. But the transverse ones above the ears, grow gradually thinner to their edges; and thus the inferior bones slightly overtop the superior ones. The bone behind the ear is the thickest in the head; for which reason, probably hair does not grow there. Over these muscles too(2), that cover the temples, a bone is situated in the middle, which is inclined to the external part. But the face has the largest suture; which beginning from the one temple runs transversely through the middle of the eyes, and the nose, to the other temple; from which two short ones point downward under the internal angles. The cheek-bones also have each of them a transverse suture in the upper part. And from the middle of the nose, or the sockets of the upper teeth, proceeds one through the middle of the palate; and another also divides the palate transversely. These then are the sutures found in most people.

The largest foramina of the head are those of the eyes; next the foramina of the nose; then those we have at the ears. The foramina of the eyes run straight and undivided to the brain. Two foramina are observed in the nose, divided by a bone in the middle: for these about the eye-brows and angles of the eyes begin osseous, and so proceed near the third part of the way; then turning cartilaginous, the nearer they approach to the mouth, so much the softer and more fleshy they become. But these foramina, which from the beginning of the nostrils to the internal part are simple, are there again divided each into two courses; the branches opening into the fauces both emit and receive the breath; the others go to the brain; in the end they are branched into many small openings, which afford the sense of smelling. In the ear too the passage at first is straight, and simple, but farther in, it becomes winding; the part next the brain is separated into many and small openings, from which we have the faculty of hearing. Near these there are as it were two small sinuses; and above them, that bone terminates, which going in a transverse direction from the cheeks is sustained by the inferior bones. It may be called jugale from the same resemblance, which gave it the Greek name of Zygodes[HW]. The maxilla is a soft bone(3), and only one in number: the middle and lowest part of which compose the chin; from whence it proceeds on both sides to the temples; and this only moves: for the malæ with the whole bone, that contains the upper teeth, are immoveable: but the extremities of the maxilla shoot as it were into two horns. One of these processes is broader below(4), and is narrowed at the vertex, and being extended forward enters below the os jugale, and over that is tied down by the muscles of the temples. The other is shorter and rounder, and is lodged like a hinge in that cavity, which is near the foramina of the ear; and there turning itself different ways, gives the maxilla a power of moving.

[HW] ζυγὼδες.

The teeth are harder than bone; part of them are fixed in the lower jaw-bone, and part in the upper. The four first from their cutting are by the Greeks called tomici[HX]. On each side of these _above and below_ stand the four canine teeth; beyond which there are commonly five maxillary teeth, except in those, in whom the genuine (_dentes sapientiae_) which generally grow late, have not come out. The fore teeth adhere each by one root, the maxillary by two at least, some by three or four. And a longer root commonly emits a shorter tooth; and the root of a straight tooth is straight, that of a crooked one bent. From this root in children, a new tooth springs, which most frequently forces out the former; sometimes however it appears above or below it.

[HX] τομικοὶ.

Next to the head is the spine, which consists of twenty-four Vertebræ. There are seven in the neck, twelve by the ribs, and the other five are below the ribs. These are round and short, and send out two processes on each side; in the middle they are perforated, where the spinal marrow, connected with the brain, descends. The sides also between the two processes are perforated by small holes, through which, from the membrane of the brain similar small membranes proceed. And all the Vertebræ(5) (except the three uppermost) at the superior part in the processes themselves have small depressions; at the lower, on the contrary, they send out processes pointing downwards. The first then immediately sustains the head, by receiving small processes of it into two depressions; which is the reason that the surface of the head below is rendered unequal by two prominences. The second is inserted into the under part of the first, and the superior part of the second is round and narrow (_processus dentatus_) in order to admit of a circular motion, so that the first surrounding the second allows the head to move towards each side. The third receives the second in the same manner; whence the neck has great facility of motion. And indeed it would not be able to sustain the head, if straight and strong nerves on each side did not secure the neck; these the Greeks call Carotæ. For one of them in every flexure, being always stretched, prevents the upper parts from slipping further. The third Vertebra has prominences, which are inserted into that below it. All the rest are inserted each into its inferior one by processes pointing downwards; and by depressions, which they have on each side, they receive the superior, and are secured by many ligaments, and a great quantity of cartilage. And thus one moderate flexure forward being allowed, a man both stands erect for some kinds of employment, and at other times bends himself as the actions he is engaged in require.

Below the neck, the first rib is situated opposite to the shoulders. After that the six inferior ones(6) reach the bottom of the breast: and these at their origin being round, and furnished with something like small heads, are fixed to the transverse processes of the vertebræ, which are in that part a little depressed; then they grow broader, and bending outward, degenerate gradually into cartilage; and in that part being again turned gently inward, are joined to the pectoral bone: which begins strong and hard at the fauces, being excavated on each side, and terminates at the præcordia, where it is softened into a cartilage. And under the superior ribs there are five, which the Greeks call Nothæ (_spurious_) shorter, and thinner, which also gradually turn to cartilage, and adhere to the external parts of the abdomen; the lowest of these in the greatest part of it is nothing else but a cartilage.

From the neck two broad bones, one on either side, go to the shoulders, by us called scutula operta, by the Greeks Omoplatæ. These have cavities at their vertices; from the vertices they become triangular, and growing gradually broader tend to the spine; and the broader they are in any part, so much the duller is their sensation. These too at their extremity are cartilaginous, and in their back part lie as it were loose, because, unless at the top, they are fixed to no bone, but are there tied down by strong muscles and nerves.

But at the first rib(7) a little within the middle of it, a bone grows out, in that part indeed slender; but going forward, the nearer it comes to the broad bone of the scapula, it becomes thicker, and broader, bending a little inwards, which being a little enlarged at its other vertex, sustains the clavicle. This bone is crooked, and is to be reckoned amongst the hardest bones; the one end of it is joined to the bone I just mentioned before, and by the other it is fixed in a small depression of the pectoral bone, and is moved a little in the motion of the arm; and its lower head is connected by ligaments and a cartilage with the broad bone of the shoulders.

Here the humerus begins, which at both its ends is enlarged, soft, without marrow, and cartilaginous; in the middle round and hard, and containing marrow; is a little concave(8) in its fore and internal part; and convex in its posterior and external part. Now the fore part is next the breast; the posterior is toward the scapulæ; the internal next the side; and the external at the greatest distance from the side: which distinctions will afterwards appear applicable to all joints in the extremities. The upper end of the humerus is rounder than the other bones, which I have yet mentioned, and _a small part of it_ is inserted into the vertex of the broad bone of the shoulder; the greatest part, standing out of it, is secured by ligaments. But the inferior head has two processes; the intermediate space between which, is even more depressed than its extremities.

This affords a reception to the fore-arm; which consists of two bones. The Radius, which the Greeks call cercis[HY], is the superior one and shorter, and at first being more slender, with its ends round, and a little concave, receives the small tubercle of the humerus, which is secured there by ligaments and a cartilage. The cubitus is the inferior and longer; it is at first larger in its upper end, and by two vertices, as it were, standing out, fixes itself into the sinus of the humerus, which I mentioned, betwixt its two processes. The two bones of the fore arm at first(9) are close together, then separate by degrees, and meet again at the hand, their former proportions being reversed: for there the radius is pretty large, and the cubitus very small. After that the radius rising to a cartilaginous head is inserted into its neck. The cubitus is round at its extremity, and projects a little on one part. And to save frequent repetition, this ought to be known, that most bones end in a cartilage, and that every articulation is thus terminated: for it could neither be moved, unless it pressed upon something smooth, nor be joined with flesh and ligaments, unless these were connected by some matter of a middle nature.

[HY] κερκὶς.

In the hand, the first part of the palm consists of many and small bones, the number of which is uncertain. But all of them are oblong and triangular, and connected together by a peculiar kind of structure, the plain of each one being higher than another alternately; whence it happens, that the whole makes up the appearance of one bone a little concave on the internal part. But from the hand two small processes are lodged in the cavity of the radius. Then at the other end five straight bones going to the fingers, compleat the palm; from which the fingers themselves have their origin. These consist each of three bones. The conformation of them all is the same. The more internal bone has a depression in its vertex, and receives the small tubercle of the external, and these are secured by ligaments. From them arise the nails, which grow hard: and thus they adhere by their roots, not to bone, but rather to flesh. This then is the construction of the superior parts.

But the lower part of the spine ends in the hip-bone, which is transverse, and far the strongest, and defends the womb, bladder, and intestine Rectum. And this in the external part is convex; at the spine inclined backward; on the sides, that is, at the hips themselves, it has round cavities; from whence arises the bone, which is called pecten; and that being situated transversely over the intestines under the pubes, strengthens the belly; it is straighter in men, but in women more bent externally, that it may not prevent the birth.

From these proceed the thigh bones; the heads of which are still rounder than those of the humeri; though the latter have more rotundity, than is found in any of the rest. A little lower they have two processes on the fore and posterior part. From that they descend hard and full of marrow, externally convex, and are again enlarged at the inferior heads. The superior ones are inserted into the cavities of the hip-bone, as the humeri into the bones of the scapulæ; then, lower down, they slope gently inward, that they may more equally sustain the superior parts. And their inferior heads have also depressions between them, that they may be the more easily received by the bones of the leg: which articulation is covered by a small, soft, and cartilaginous bone, which is called Patella. This floating above, and not being fixed to any bone, but bound down by flesh and tendons, and a little more inclined to the thigh bone, defends the joint in all flexures of the legs.

The leg consists of two bones; for in every thing the thigh resembles the arm, and the leg the fore-arm; so that the shape and elegance of the one may be known from the other; which beginning with the bones, answers also in the flesh. One of these bones is situated on the external part of the calf of the leg, and from that properly enough takes the name of Sura(10). This is shorter and more slender above, but is enlarged at the ancles. The other, which is placed in the fore part, and has the name of Tibia, is longer and larger in the upper part, and is alone connected with the lower end of the thigh-bone, as the cubitus is with the humerus: and these bones too, being joined both below and above, separate in the middle, as those of the fore arm.

The leg bones are received below by a transverse bone in the ancle; and that is situated above the heel bone; which in one part has a depression and in another prominences, and it both receives the processes from the ancle-bone, and is inserted into its cavity. And this is hard, without marrow, and projecting more to the posterior part makes a round figure there. The other bones of the foot are constructed in a similar manner to those of the hand. The soles answer to the palms, the toes to the fingers, and the nails to the nails.

CHAP. II.

GENERAL DIVISION OF DISORDERS IN THE BONES. OF A BLACKNESS AND CARIES, AND THEIR TREATMENT.

Whenever a bone is injured, it is either corrupted, or fissured, or fractured, or perforated, or contused, or dislocated. A corrupted bone generally turns first oily, and afterwards either black or carious. These cases happen from large ulcers, or fistulas over them, when they have either grown antient, or have been seized with a gangrene. First of all it is necessary to lay bare the bone, cutting out the ulcer, and if the disorder extends farther than the ulcer was, to pare away the flesh below, till the sound part of the bone be exposed all round; then it is sufficient to cauterize the part that is oily, once or twice, by the application of an iron instrument, that so a scale may cast off; or to scrape it, till some blood appear, which is the mark of a sound bone: for whatever is vitiated must necessarily be dry. The same method must also be pursued in a cartilage that is injured; for that too must be scraped by a knife, till what remains be sound. And then what is thus scraped, whether bone or cartilage, must be sprinkled with nitre well powdered. And nothing else is to be done, where a caries or blackness is in the surface of the bone: for in that case, the cautery or the scraping must only be continued a little longer. A person, that scrapes these, ought to press the instrument boldly, that he may both do it effectually, and have the sooner done. The operation is finished, when we come to the white or firm bone. It is evident, that when the defect is a blackness, it ends in the white, and that where there is a certain degree of solidity, there the caries terminates. We have already observed, that there is also some blood in a sound bone: But when either of these happen to go in pretty deep, it is uncertain where they end.

It is easy to form a judgment in a caries, if a small probe is introduced into the foramina, which by penetrating more or less, shews that the caries is either in the surface, or of greater depth. The same may be collected(11) even from the pain and fever; for when these are moderate, it cannot have penetrated deep. A greater certainty is obtained however by the application of the perforator: for the disease ends, where the dust of the bone ceases to be black. Therefore if the caries has gone deep, several holes must be made in it by the perforator, as deep as the disease goes; then into these holes must be put hot irons, till the bone become entirely dry. For the consequences of this operation will be, that whatever is spoilt will be separated from the bone below; and the cavity will be filled up with flesh; and afterwards either no humour at all, or a small quantity will be discharged.

But if the blackness goes through(12) to the other side of the bone, it ought to be cut out. The same may be done also in a caries, that penetrates to the other side of the bone. But where the whole is spoilt, the whole must be taken away. If the inferior part is sound, so far as is corrupted, ought to be cut out. Likewise if the skull or pectoral bone, or a rib be carious, the actual cautery is needless, but there is a necessity for excision. Neither does the opinion of these people deserve our attention, who defer the excision to the third day after the bone is laid bare, before they cut it out; for in all cases it is safer to perform an operation, before an inflammation come on. Therefore both the skin is to be cut, and the bone laid bare, and freed from every fault, as far as possible, in the same moment. Now a disease in the pectoral bone is far the most pernicious of any; because though the operation have succeeded well, it hardly ever restores a perfect soundness.

CHAP. III.

OF THE USE OF THE MODIOLUS AND PERFORATOR, AND OTHER INSTRUMENTS, ESPECIALLY FOR THE BONES OF THE HEAD.

There are two ways of cutting out a bone; if the part injured be very small, by a modiolus, which the Greeks call chœnicion[HZ], if larger by terebræ. I shall explain the method of each. The modiolus is a concave and round iron instrument with serrated edges in its lowest extremity; through the middle of which is put a pin, surrounded also by an interior circle. Of perforators there are two kinds: one of them resembling that, which carpenters use; the other with a longer head, which begins from a sharp point, and then turns quickly broader; and again from another beginning goes upward with thickness pretty near equal.

[HZ] χοινίκιον. This was the name of a measure among the Greeks, and
from its resemblance in shape, they have probably used the same word
for this chirurgical instrument; for the same reason, I suppose the
Romans have named it _modiolus_. Though I have chosen to retain our
author’s term, yet the reader will see the difference is not material
betwixt that, and the trepan of our surgeons; the terebra comes so
near to the perforator, that I have used the modern term for it.

If the disease be confined to a small space, so that the modiolus can cover it, that must be used preferably. But if a caries appear below, the pin in the middle is put into the opening. If there be a blackness, a small hole is made by the angle of a chisel(13) to receive the pin, that the modiolus resting upon that, by being turned round may not slip, and then it is turned like the perforator by a strap. And there is a certain degree of pressure required, that both a perforation may be made, and it may go round; because if it be lightly impressed, it does not produce the effect; if too much, it has no motion. And it is not improper to drop in a little rose oil or milk, the smoothness of which may make it turn with the greater ease; yet too much of the liquid blunts the edge of the instrument. But when the modiolus has marked out a way for itself, the middle pin is taken out, and it is worked about by itself. And then, when the soundness of the inferior part is discovered by the dust, the modiolus is taken away.

But if the disease is more extended than to be covered by that, we must make use of the perforator. By this a hole is made in the limit, that divides the injured from the sound part of the bone; and not far from that a second, and a third, till the part, that is to be cut out, be surrounded with these holes. And in this case too the dust indicates how deep the perforator is to go. Then a chisel being drove by a mallet from one hole to another, cuts out the intermediate space between them; and thus a circumference is formed like to that, which is imprinted in a smaller circle by the modiolus. In whichever way the circle has been made, let the same chisel, laid flat on the corrupted bone, smooth each superior lamina, till the bone be left entirely sound.

A blackness hardly ever goes quite through a bone, but a caries does, especially where the skull is faulty. There also the disorder is discovered by the probe, which being introduced into the hole, that terminates at the sound part of the bone, both finds some resistance, and comes out moist. If it prove pervious, the probe going in deeper between the bone and the membrane, meets with no resistance, and comes out dry: not because there is no corrupt sanies within, but because it is there diffused, as being in a larger cavity.

Now whether a blackness, which the perforator has discovered, or a caries, which the probe has shewn, pass through the bone, the use of the modiolus is generally fruitless: because, where the disease has penetrated so deep, it must also necessarily be largely extended in breadth. Here then we must use the second kind of perforator above described; and to prevent its growing too hot, it must be dipped now and then in cold water. But then we must proceed with greater caution, when we have perforated either half through in a simple bone, or the superior lamina in a double one. The space itself guides us in the first case; and in the other, the blood. Therefore at that time the strap must be drawn slower, the left hand should press more gently, and be taken off pretty frequently: also the depth of the perforation is to be considered, that we may be sensible whenever the bone is broke through, and run no risque of wounding the membrane of the brain by its point, from which proceed violent inflammations, with danger of death.

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.

[IA] Μηνιγγοφύλαξ: the etymology of this word answers exactly to its
use: it is delineated by Scultet. tab. 2. fig. 9.

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.

[IB] λεπὶς.

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.

In almost every fissure, or fracture of the bone, the ancient physicians had immediate recourse to instruments to cut it. But it is far the best method, first to try plaisters that are composed for the skull. Some one of these, it is proper to soften with vinegar, and apply alone upon the fissured or fractured bone; then over that, somewhat broader than the wound, a piece of linen spread with the same medicine, and besides that, sordid wool dipped in vinegar; then to bind up the wound, and open it again every day; and dress it in this manner for five days; from the sixth, to foment it also with the vapour of hot water by a spunge, continuing all the former treatment. And if granulations begin to grow, if the febricula is either gone, or abated, if the appetite has returned, and the patient gets sufficient sleep, we must continue the same dressings. Some time after, the plaister must be softened, with the addition of a cerate made of rose oil, to promote the growth of flesh: for, by itself, it has a repellent quality. By this method often the fissures are filled with a kind of callus, which is as it were a cicatrix in a bone. And in large fractures, if the bones do not cohere together in any part, they are united by the same callus; and this is a far better covering to the brain, than the flesh that grows, when the bone is cut out. If, under the first treatment, the fever increases, the sleeps are short and disturbed by dreams, the ulcer is moist and does not fill, small glandular swellings rise in the neck; the pains are violent; and with all these the loathing of food increases; then, and only in that case, recourse must be had to the hand and the chisel.

There are two dangers attending a blow upon the skull; that it be either split, or depressed in the middle. If it is fissured, the lips of it may be compressed; either because one of them rises above the other, or even because they have run together again with force: whence it happens, that a humour descends upon the membrane, and has no vent, and thus irritates it, and brings on violent inflammations.

When the bone is depressed in the middle, it presses upon that same membrane of the brain; and sometimes also some sharp points from the fracture, prick it. In the cure of these cases as little as possible must be taken off the bone. Therefore, if one edge rests upon the other, it is sufficient to cut off the prominence with a plain chisel. After that is removed, if the fissure gapes a little, it is enough for the cure. But if the edges are compressed together, an opening must be made with the perforator, at a finger’s breadth distance on one side, and from that the chisel must be carried in two lines, to the fissure, in the form of the letter Λ: so that the vertex of it may be at the opening, and the base at the fissure.

But if the fissure extends to a great length, it will be proper to repeat the operation from another foramen; and thus nothing that is broke off can be concealed under the bone, and a large opening is procured for whatever is hurtful within. Nor is it necessary to cut out the whole of a fractured bone, though it be depressed; but if it be either entirely broke through, and has separated wholly from the cranium, or if it adhere to _the surrounding skull_ in a small part, it must be divided from the sound bone by the chisel. Then in the depressed bone, near the fissure we have made, holes must be bored; if the injured part be small, two; if larger, three; and the spaces betwixt these must be cut out; and then the chisel must be drove on both sides to the fissure, in such a manner as to make a semicircular cavity, and let the middle part be toward the fracture, and the horns point to the sound bone. Then if any pieces be loose, and can be easily taken away, they must be removed by the forceps, which is made for that purpose, especially those sharp pieces, which irritate the membrane. If this cannot be easily done, the plate, which I called meningo-phylax, must be put below it; and above that whatever is prickly, and stands inward, must be cut off; and whatever is depressed inward must be raised by the same plate. The effect of such treatment is, that the fractured bones, if they adhere together in any part, may be consolidated; and wherever they are broke away, in time they may be separated by medicines without any pain; and at the same time a space may be left sufficiently large between them, to evacuate the sanies; and the brain may have a better protection from the bone than it would have had, if that were cut out.

After these things are done, the membrane must be sprinkled with sharp vinegar; that, if there be a discharge of blood from it, it may be restrained, or if any blood remain coagulated within, it may be discussed; then the same medicine must be applied, softened in the manner above prescribed, to the membrane itself; the other directions, which relate to the linen spread, and the sordid wool, must be observed in the same manner, and the patient must be kept in a warm place, and the wound dressed every day; and in summer even twice.

But if, by reason of an inflammation, the membrane has swelled, warm rose oil must be infused upon it. If it shall swell to such a height as to rise above the bones, it will be restrained by lentils well powdered, or vine leaves powdered, and mixed with either fresh butter, or recent goose fat; and the neck will require to be mollified by liquid cerate made of iris ointment. But if the membrane shall appear not to be clean, equal quantities of the plaister and honey must be mixed; which must be infused upon it; and to keep that on, a piece of lint or two must be clapped on, and that again covered with a linen cloth spread with a plaister. When the membrane is sufficiently clean, cerate must be added in the same manner to the plaister to promote the growth of flesh.

As to abstinence, and the food, and drink, in the first and more advanced stages of the cure, the same rules must be observed which I prescribed in wounds, and with the greater exactness, by how much a hurt in this part is more dangerous. Nay even when it shall be fit to allow such a quantity of food as not barely to sustain the patient, but to nourish him, yet every thing that requires chewing must be avoided; also smoke, and whatever excites sneezing. The membrane being moveable, and of its natural colour, granulations of ruddy flesh, and an easy motion of the lower jaw and neck, afford certain hopes of recovery. The bad signs are, the membrane immoveable, black, livid, or of any other vitiated colour; a delirium, acrid vomiting, a palsy, or convulsion, livid flesh, or rigor of the jaws and neck. The other symptoms that relate to sleep, appetite, fever, and the colour of the pus, are either salutary or mortal, as in other wounds.

When the case succeeds well, the growth of flesh begins from the membrane itself; or if the bone in that part be double, it sprouts from thence too, and fills up the void space between the bones; sometimes it even rises higher than the surface of the skull. If that happens, copper scales must be sprinkled on to keep it down; and medicines applied to bring a cicatrix over it, which is easily obtained in every place, except the part of the forehead, which is a little above the space that lies between the eyebrows (_sinus frontalis_): for there, an ulceration for the whole life after, can hardly be prevented; this must be covered with a linen cloth spread with a medicine. And the following directions must be always observed in a fractured skull, that till the cicatrix be strong, the sun, wind, frequent bathing, and excess in wine be avoided.

CHAP. V.

OF FRACTURES OF THE NOSE.

In the nose, both the bone and the cartilage are liable to be fractured; and that sometimes happens in the fore part, sometimes on one side. If either both, or one of them be fractured in the fore part, the nostrils fall in, and the breath is drawn with difficulty. If the bone is fractured on one side, that part is hollow; if the cartilage, the nostrils are turned to the opposite side.

Any part of the cartilage, that has given way, must be gently raised, either by a probe put under it, or two fingers compressing it on both sides; then lint platted of a due length, sewed up in soft leather, must be put within; or some part of a dry penecillum composed in the same manner; or a large quill dipped in gum or joiner’s glue, and covered with soft leather, which prevent the cartilage from sinking in. But if the fracture be in the fore part, both nostrils are to be equally filled. If on one side, what is put in ought to be thicker in that part where the nose falls in, and smaller on the other; and externally, a soft strap must be carried round, the middle of which is spread with fine flour and soot of frankincense mixed together; and this must be drawn beyond the ears, and the two ends being crossed there and returned, are to be glued to the forehead: for it sticks to the skin like glue, and when it has grown hard, it keeps the nostrils firm. But if what is put within gives pain, which happens chiefly where the interior part of the cartilage is broke through, the nostrils being raised in the same(14) manner, must be only held firm by the strap abovementioned; then, after fourteen days, that must be removed; it is to be separated by hot water, with which also the swelled part(15) must be fomented every day.