De Medicina |
Translator: Walter George Spencer
|
|
| 189 |
Exciditur uero os duobus modis : si paruulum est , quod laesum est , modiolo , quam ΧΟΙΝΕΙΚΙΔΑ Graeci uocant ; si spatios ius , terebris . Vtriusque rationem proponam . Modiolus ferramentum concauum , teres est , imis oris serratum , per quod medium clauus ipse quoque interiore orbe cinctus demittitur . Terebrarum autem duo genera sunt : alterum simile ei , quo fabri utuntur , alterum capituli longioris ; quod ab acuto mucrone incipit , dein subito latius fit , atque iterum ab alio principio paulo minus quam aequaliter sursum procedit . Si uitium in angusto est , quod conprehendere modiolus possit , ille potius aptatur ; et , si caries subest , medius clauus in foramen demittitur ; si nigrities , angulo scalpri sinus exiguus fit , qui clauom recipiat , ut eo insistente circumactus modiolus delabi non possit ; deinde is habena quasi terebra conuertitur . Estque quidam premendi modus , ut et foretur et circumagatur ; quia si leuiter inprimitur , parum proficit ; si grauiter , non mouet ur. Neque alienum est instillare paulum rosae uel lactis , quo magis lubrico circumagatur ; quod ipsum tamen , si copiosius est , aciem ferramenti hebetat . Vbi iam iter modiolo pressum est , medius clauus educitur , et ille per se agitur ; dein cum sanitas inferioris partis scobe cognita est , modiolus remouetur . At si latius uitium est quam ut illo conprehendatur , terebra res agenda est . Ea foramen fit in ipso fine uitiosi ossis atque integri ; deinde alterum non ita longe , tertiumque ; donec totus is locus , qui excidendus est , his cauis cinctu s sit ; atque ibi quoque quatenus terebra agenda sit , scobis significat . Tum excissorius scalper ab altero foramine ad alterum malleolo adactus id , quod inter utrumque medium est , excidit ; ac sic ambitus similis ei fit , qui in angustiore m orbe m modio lo inprimitur . Vtr o modo uero id circumductum est , idem excissorius scalper in osse corrupto planissumam quamque testam †laesit , donec integrum os relinquatur . Vix umquam nigrities , inte rdum caries per totum os perrumpit , maximeque ubi uitiata caluaria est . Id quoque signi specillo significatur , qu od depressu m in id foramen , quod infra solidam sedem habet , ob id re nitens aliquid inuenit , et madens exit . Si peruium inuenit , altius descendens inter os et membranam nihil oppositum inuenit , educiturque siccu m : non quo non subsit aliqua uitiosa sanies , sed quo ibi ut in latiore sede diffusa sit . Siue autem nigrities , quam terebra detexit , siue caries , quam specillum ostendit , os transit , modioli quidem usus fere superuacuus est , quia latius pateat necesse est , quod tam alte processit . Terebra uero ea , quam secundo loco posui , utendum ; eaque ne nimis incalescat , subinde in aquam frigidam demittenda est . Sed tum maiore cura agendum est , cum iam aut simplex os dimidium perforatum est , aut in duplici superius : illud spatium ipsum , hoc sanguis significat . Ergo tum lentius ducenda habena suspendendaque manus sinistra est et saepius attollenda , et foraminis altitudo consideranda , ut , quandoque qui perrumpatur , sentiamus , neque periclitemur , ne mucrone cerebri membrana laedatur ; ex quo graues inflammationes cum periculo mortis oriuntur . Facti s foraminibus , eodem modo media saepta , sed multo circumspectius , excidenda sunt , ne forte angulus scalpri eandem membranam uiolet ; donec fiat aditus , per quem membranae custos inmittatur : menin gophylaca Graeci uocant . Lammina aenea est , prima paulum resima , ab exteriore parte leuis ; quae demissa sic , ut exterior pars eius cerebro propior sit , subinde ei subicitur quod scalpro discutiendum est ; ac , si excipit eius angulum , ultra transire non patitur ; eoque et audacius et tutius scalprum malleolo medicus subinde ferit , donec undique excisum os eadem lammina leuatur , tollique sine ulla noxa cerebri potest . Vbi totum os eiectum est , circumradendae leuandaeque orae sunt , et , si quid scobis membranae insedit , colligendum . Vbi superiore parte sublata relicta inferior est , non orae tantum sed os quoque totum leuandum est , ut sine noxa postea cutis increscat , quae aspero osse nascens protinus non sanitatem , sed nouos dolores mouet . Patefacto cerebro qua ratione agendum sit , dicam , cum ad fracta ossa uenero . Si bas sis aliqua seruata est , superinponenda sunt medicamenta non pinguia , quae recentibus uulneribus ac commodantur ; supraque inponenda lana sucida oleo atque aceto madens . Vbi tempus processit , ab ipso o sse caro increscit , eaque factum manu sinum complet . Si quod etiam os adustum est , a parte sana recedit , subi tque inter integram atque emortuam partem caruncula , quae quod apscessit expellat ; eaque fere , quia testa tenuis et angusta est , squama a Graecis nominatur . Potest etiam euenire , ut ex ictu neque findatur os neque perfringatur , sed summum tamen collidatur exaspereturque ; quod ubi incidit , radi et leuari satis est . Haec quamuis maxime fiunt in capite , tamen ceteris quoque ossibus communia sunt , ut ubicumque idem incidit , eodem remedio sit utendum . At quae FRACTA , fissa , forata , collisa sunt , quasdam proprias in singulis generibus , quas dam communes in pluribus curationes requirunt ; de quibus protinus dicam , initio ab eadem caluaria accepto .
|
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. |
| 190 |
Igitur ubi ea percussa , protinus requirendum est , num bilem homo is uomuerit , num oculi eius occaecati sint , num obmutuerit , num per nares auresue sanguis ei fluxerit , num conciderit , num sine sensu quasi dormiens iacuerit : haec enim non nisi osse fracto eueniunt ; atque ubi inciderunt , scire licet necessariam sed difficilem curationem esse . Si uero etiam torpor accessit , si mens non constat , si neruorum uel resolutio uel distentio secuta est , uerisimile est etiam cerebri membranam esse uiolatam ; eoque in angusto magis spes est . At si nihil horum secutum est , potest etiam dubitari , an os fractum sit ; et protinus considerandum est , lapide an ligno an ferro an alio telo percussus sit , et hoc ipso le ui an aspero , mediocri an uastiore , uehementer an leuiter , quia quo mitior ictus f uit, eo facilius os ei restitisse credibile est . Sed nihil tamen melius est quam certiore id nota explorare . Ergo qua plaga est , demitti specillum oportet , neque nimis tenue neque acutum , ne , cum in quosdam naturales sinus inciderit , opinionem fracti ossis frustra faciat ; neque nimis plenum , ne paruolae rim ulae fallant . Vbi specillum ad os uenit , si nihil nisi leue et lubricum occurrit , integrum id uideri potest ; si quid asperi est utique qua suturae non sunt , fractum os esse testatur . A suturis se deceptum esse Hippocrates memoriae prodidit , more scilicet magnorum uirorum et fiducia m magnar um rer um habentium . Nam leuia ingenia , quia nihil habent , nihil sibi detrahunt : magno ingenio , multaque nihilo minus habituro , conuenit etiam simplex ueri confessio praecipueque in eo ministerio , quod utilitatis causa posteris traditur , ne qui decipiantur eadem ratione , qua quis ante deceptus est . Sed haec quidem alioqui memoria magni professoris ut interponeremus effecit . Potest autem sutura eo nomine fallere , qu ia aeque aspera est ; ut aliquis hanc esse , etiamsi rima est , existimet eo loco , quo subesse hanc verisimile est . Ergo eo nomine decipi non oportet , sed os deoperire tutissimum . Nam neque utique certa sedes , ut supra posui , suturarum est , et potest idem et naturaliter commissum et ictu fissum esse iuxtaue aliquid fissum habere . Quin aliqu ando etiam , ubi ictus fuit uehementior , quamuis specillo nihil inuenitur , tamen aperire commodius est . Ac si ne tum quidem rima manifesta est , inducendum super os atramentum scriptorium est , deinde scalpro id deradendum : nigritiem enim continet , si quid fissum est . Solet etiam euenire , ut altera parte fuerit ictus , et os altera fiderit . Itaque si grauiter aliquis percussus est , si mala indicia subsecuta sunt , neque ea parte , qua cutis discussa est , rima reperitur , non incommodum est parte altera considerare , num qui locus mollior sit et tumeat , eumque aperire , siquidem ibi fissum os reperietur . Nec tamen magno negotio cutis sanescit , etiamsi frustra secta est . Os fractum , nisi si succursum est , grauibus inflammationibus adficit , difficiliusque postea tractatur . Raro sed aliquando tamen euenit , ut os quidem totum integrum maneat , intus uero ex ictu uena aliqua in cerebri membrana rupta aliquid sanguinis mittat , isque ibi concretus magnos dolores moueat , * oculos quibus dam obcaecet . Sed fere contra id dolor est et eo loco cute incisa pallidum os reperitur ; ideoque id quoque os excidendum est . Quacumque autem de causa curatio haec necessaria est , si nondum satis cutis patefacta est , latius aperienda est , donec quicquid laesum est in conspectu sit . In quo ipso uidendum est , ne qui d ex ima membranula , quae sub cute caluariam cingit , super os relinquatur , siquidem ea scalpro terebrisue lacerata uehementes febres cum inflammationibus excitat ; itaque eam commodius est ex toto ab osse deduci . Plagam , si ex uulnere est , talem necesse est habeamus , qualem acceperimus : si manu facienda est , ea fere commodissima est , quae duabus transuersis lineis litterae X figuram accipit ; tum deinde a singulis procedentibus lingulis cutis subsecatur . Inter quae si sanguis fertur , spongia subinde in aceto tincta cohibendus est , occupandusque est obiectis linamentis et caput altius excitandum . Neque id ullum metum , nisi inter musculos qui tempora continent , adfert : sed ibi quoque nihil tutius fit . In omni uero fisso fractoue osse protinus antiquiores medici ad ferramenta ueniebant , quibus id exciderent : sed multo melius est ante emplastra experiri , quae caluariae causa conponuntur . Eorumque aliquod oportet ex aceto mollitum per se super fissum fractumue os inponere ; deinde super id aliquanto latius quam uulnus est eodem medicamento inlitum linteolum , et praeterea sucidam lanam aceto tinctam ; tum uulnus deligare et cotidie resoluere , similiterque curare usque ad diem quintum , a sexto die etiam uapore aquae calidae per spongiam fouere , cetera eadem facere . Quod si caruncula increscere coeperit et febricula aut soluta erit aut breuior et cupiditas cibi reuerterit , satisque somni accedet , in eodem medicamento erit perseuerandum . Procedente deinde tempore , emolliendum id emplastrum adiecto cerato ex rosa facto , quo facilius carnem producat : nam per se reprimendi uim habet . Hac ratione saepe rimae callo quodam inplentur estque ea ossis uelut cicatrix ; et latius f racta ossa , si qua inter se non cohaerebant , eodem callo glutinantur estque id aliquanto melius uelamentum cerebro quam caro , quae exciso osse increscit . Si uero sub prima curatione febris intenditur breuesque somni et idem per somnia tumultuosi sunt , ulcus madet neque alitur , et in ceruicibus glandulae oriuntur , magni dolores sunt , cibique super haec fastidium increscit , tum demum ad manum scalprumque ueniendum est . Duo uero sub ictu caluariae pericula sunt , ne uel findat ur os uel medium desidat . Si fissum est , possunt orae esse conpressae , uel quia altera super alteram excessit , uel etiam quia uehementer se rursus commiserunt . Ex quo euenit , ut umor ad membranam quidem descendat , exitum uero non habeat ac si c eam inritet et graues inflammationes moueat . A t ubi medium desedit , eandem cerebri membranam os urget interdum etiam ex fractura quibusdam uelut aculeis pungentibus . His ita succurrendum est , ut tamen quam minimum ex osse dematur . Ergo si ora alteri insed it , satis est id quod eminet , plano scalpro excidere ; quo sublato iam rima hiat quantum curationi satis est . At si orae inter se conprimuntur , a latere eius interposito digiti spatio terebra foramen faciendum est ; ab eoque scalper duabus lineis ad rimam agendus ad similitudinem †c litterae sic , ut ue rtex eius a foramine , basis a rima sit : quod si rima longius patet , ab altero foramine rursus similis sinus fieri debebit . Et ita †nihil latens in eo osse cauum est abundeque exitus datur intus laedentibus . Ne si fractum quidem os desedit , totum excidi necesse est . Sed siue totum perfractum est et ab alio ex toto recessit siue circumpositae caluariae inhaeret exigua parte , ab eo , quod naturaliter se habet , scalpro diuidendum est . Deinde in eo , quod desedit , iuxta rimam , quam fecimus , foramina addenda sunt ; si in angusto noxa est , duo ; si latius patet , tria ; saeptaque eorum excidenda ; et tum scalper utrimque ad rimam agendus sic , ut lunatum sinum faciat imaque pars eius intus ad fracturam , cornua ad os integrum spectent . Dein , si qua labant et ex facili remoueri possunt , forfice ad id facta colligenda sunt , maximeque ea , quae acut a membranam infestent . Si id ex facili fieri non potest , subicienda lammina est , quam custodem eius membranae esse proposui ; ut super , quicquid spinosum est et intus eminet , excidatur ; eademque lammina , quicquid deorsum insedit , attollendum . Hoc genus curationis efficit , ut qua parte fracta ossa tamen inhaerent , solidentur ; qua parte abrupta sunt , sine ullo tormento sub medicamento tempore excidant ; spatiumque inter haec satis illa magnum ad extrahendam saniem relinquatur ; plusque in osse propugnaculi cerebrum habeat , quam habiturum fuit eo exciso . His factis , ea membrana acri aceto respergenda est , ut , siue aliquid sanguinis ex ea profluit , cohibeatur , siue intus concretus cruor remanet , discutiatur . Tum idem medicamentum eodem modo , qui supra positus est , mollitum ipsi membranae inponendum est ; ceteraque eodem modo facienda sunt , quae ad linteolum inlitum et lanam sucidam pertinent ; conlocandusque is loco tepido ; curandum cotidie uulnus , bis etiam aestate . Quod si membrana per inflammationem intumuerit , infundenda erit rosa tepida ; si usque eo tumebit , ut super ossa quoque emineat , coercebit eam bene trita lenticula uel folia uitis contrita , et cum recenti uel buturo uel adipe anserina mixta ; cerui xque molliri debebit liquido cerato ex irino facto . At si parum pura membrana uidebitur , par modus eius emplastro et melli miscendus erit , idque super infundendum ; eiusque continendi causa unum aut alterum linamentum iniciendum , et super linteolo , cui emplastrum inlitum sit , contegendum . Vbi pura membrana est , eadem ratione adiciendum emplastro ceratum , ut carnem producat . Quod ad abstinentiam uero et primos ulterioresque cibos potionesque pertinet , eadem , quae in uulneribus praecepi , seruanda sunt , eo magis , quo periculosius haec pars adficitur . Quin etiam , cum iam non solum sustineri sed ali is quoque oportebit , tamen erunt uitanda , quaecumque mandenda sunt ; item fumus et quicquid excitat sternumentum . Spem uero certam faciunt membrana mobilis ac sui coloris , caro increscens rubicunda , facilis motus maxillae atque ceruicis . Mala signa sunt membrana inmobilis , nigra uel liuida uel aliter coloris corrupti ; dementia , acris uomitus , neruorum uel resolutio uel distentio ; caro liuida , maxillarum rigor atque ceruicis . Cetera , quae ad somnum , cibi desiderium , febrem , puris colorem attinent , eadem , quae in ceteris uulneribus , uel salutaria uel mortifera sunt . Vbi bene res cedit , incipit ab ipsa membrana uel si os eo loco duplex est inde quoque caro increscere ; eaque id , quod inter ossa uacum est , replet : nonnumquam etiam super caluariam excrescit . Quod si incidet , inspergenda squama aeris est , ut id reprimat cohibeatque . Ea carni superdanda , quae ad cicatricem perducant . Omnibusque ea locis commode inducitur excepta frontis ea parte , quae paulum super id est , quod inter supercilia est : ibi enim ui x fieri potest , ut non per omnem aetatem sit exulceratio ; quae linteolo medicamentum habente contegendas t . Illa utique capite fracto seruanda sunt , ut , donec iam ualida cicatrix sit , uitentur sol , uen tus , frequens balineum , maior uini modus .
|
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. |
| 191 |
In naribus uero et os et cartilago frangi solet , et quidem modo aduersa , modo a latere . Si aduersa am bo fracta sunt alterumue ex is , nare s desidunt , difficulter spiritus trahitur : si a latere os fractum est , is locus cauus est ; si cartilago , in alteram partem nares declinantur . Quicquid in cartilagine incidit , excitand a ea leniter est aut subiecto specillo aut duobus digitis utrimque conpressis ; deinde in longitudinem inplicata l inamenta et molli pellicula cincta circumsutaque intus adigenda sunt ; aut eodem modo compositum aliquid ex arido penicillo ; aut grandis pinna cummi uel fabrili glutine inlita et molli pellicula circumdata , quae desidere cartilaginem non sinat . Sed si aduersa ea fracta est , aequaliter utraque naris inplenda est : si a latere , crassius esse debet ab ea parte , in quam nasus iacet , ab altera tenu ius id quod inseritur . Extrinsecus autem circumdanda habena est mollis , media inlita mixtis inter se simil a et turis fuligine ; eaque ultra aures ducenda et fronti duobus capitibus adglutinanda est : id enim corpori quasi gluten inhaerescit et , cum induruit , nares commode continet . Sin quod intus inditum est laedit , sicut maxime fit , ubi interior cartilago perfracta est , excitatae nares eadem tantummodo habena continendae sunt ; deinde post quattuordecim dies id ipsum demendum est . Resoluitur autem aqua calida , eaque tum is locus cotidie fouendus . Sin os fractum est , id quo que digitis in suam sedem reponendum est ; atque ubi aduersum id ictum est , utraque naris inplenda est ; ubi a latere , ea , in quam os inpulsum est ; inponendumque ceratum , et paulo uehementius deligandum est , quia callus eo loco non ad sanitatem tantummodo , sed etiam ad tumorem increscit . A tertio die fouendum id aqua calida est , tantoque magis , quanto propius esse sanitati debet . Quod si plura erunt fragmenta , nihilo minus extrinsecus singula in suas sedes digitis erunt conpellenda ; inponendaque extrinsecus eadem habena , et super eam ceratum ; neque ultra fascia adhibenda est . At si quod fragmentum undique resolutum cum ceteris non glutinabitur , intellegetur quidem ex umore , qui multus ex uulnere feretur , uolsella uero extrahetur ; finitisque inflammationibus , inponetur aliquod medicamentum ex is , quae leniter reprimunt . Peius est , ubi aut ossi aut cartilagini fractae cutis quoque uulnus accessit . Id admodum raro fit . Si incidit , illa quidem nihilo minus eadem ratione in suas sedes excitanda sunt : cuti uero superinponendum emplastrum aliquod ex is , quae recentibus uulneribus accommodata sunt : sed insuper nullo uinculo deligandum est .
|
5 In the nostrils again either the bony or cartilaginous part may be broken, and that either in front, or to one side. If both are broken across, or one of them, the nose sinks in and the breath is drawn through with difficulty; if bone on one side is broken, there is a depression; if cartilage, the nose is bent to the opposite side. Whatever occurs in the case of the cartilage, it must be gently raised either by passing a probe under it or by compressing with a finger on each side; then a roll of folded linen with thin leather sewn on over it is introduced; or some sort of dry pad similarly shaped; or a large quill smeared with gum or joiner's glue, and wrapped round with soft thin leather, which will prevent the cartilage from sinking in again. But if broken across, both nostrils are to be filled equally; if on one side, the nostril on the side to which the nose is bent should be filled with a thicker roll, the other nostril with a thinner one. Outside also a strap of soft leather, the middle smeared with a mixture of fine flour and incense soot, is applied, and it must be carried back behind the ears and fastened to the forehead by its two ends. The flour and incense when dried sticks to the skin like glue and keeps the nose in place. If what has been inserted causes irritation, as happens mostly when the septal cartilage inside is fractured, the nostrils are to be raised and kept in place by the strip of leather alone; then this too is removed at the end of a fortnight after loosening with warm water, and afterwards every day the nose should be fomented with the same. But if the bone is broken, this also is put back into position by the finger; and when the injury is in front, both nostrils are plugged; when on one side, the nostril on the side towards which the bone has been displaced. Cerate is to be applied, and the part bound fairly tightly, because in this position callus grows not only sufficiently to cause union, but even into a tumour. From the third day the nose is to be fomented with hot water, more especially as it begins to unite. Even if there are several fragments, each is to be forced into place by the fingers applied outside, and the strip in the same way is to be put on outside, and a cerate over it, and no additional bandage. But if any fragment has become completely separated and will not unite with the rest, this will be recognized by the fluid which is discharged freely from the lesion; then the fragment should be extracted by means of a forceps; when the inflammatory reaction is at an end, some medicament from among the mild repressants is applied. The case is worse when there is an external wound as well as a fracture, whether of bone or cartilage. This only occurs rarely. If it does happen, the fragments are to be replaced into position in the same way, while the skin is dressed with one of the plasters suitable for recent wounds; but no bandage must be put over it. |
| 192 |
In aure quoque interdum rumpitur cartilago . Quod si incidit , antequam pus oriatur , inponendum glutinans medicamentum est : saepe enim suppurationem prohibet et aurem confirmat . Illud et in hac et in naribus ignorari non oportet , non quidem cartilaginem ipsam glutinari , circa tamen carnem increscere solidarique eum locum . —Itaque si cum cute cartilago rupta est , cutis utrimque suitur . Nunc autem de ea dico , quae cute integra frangitur . In ea uero si iam pus natum est , aperienda altera parte cutis et ipsa cartilago contra lunata plaga excidenda est ; deinde utendum est medicamento leniter supprimente , quale Lycium est aqua dilutum , donec sanguis fluere desinat ; tum inponendum linteolum cum emplastro sic , ut pingue omne u itetur , et a parte posteriore lana mollis auri subicienda est , quae quod est inter hanc et caput compleat ; tum ea leniter deliganda est , et a tertio die uapore , ut in naribus posui fouenda . Atque in his quoque generibus abstinentia primi temporis necessaria est , donec inflammatio finiatur .
|
6 In the ear also the cartilage is sometimes ruptured. If this happens, before suppuration has supervened, an agglutinating medicament should be put on; for this often prevents suppuration, and cures the ear. As in the case of the nose, it must not be overlooked that the cartilage itself does not agglutinate, but flesh grows round it and so the place becomes consolidated. Hence, if the skin is torn along with rupture of the cartilage, the skin on both sides is to be stitched. But I speak now of a case where the cartilage is broken, but the skin intact. Now in that case if suppuration supervenes, the skin on the other side is to be laid open and a crescent-shaped piece of cartilage cut out beneath; then a mild styptic such as lycium dissolved in water is put on until bleeding ceases; next lint smeared with a plaster without any grease is applied and soft wool to fill the space between the ear and the head; then the ear is lightly bandaged, and from the third day the ear is steamed as in the case of the nose (5.4). In these kinds of injuries also fasting is necessary at first until inflammation has ceased. |