Rome-Galen (129 to ca. 216).

Over the last 50 years the significance of Galen's contributions to the arts of medicine and surgery have been increasingly recognized. Despite his errors, his contributions to medical and surgical practice have been profound. In the present context, his teachings on cranial surgical instruments and technique would continue to be influential throughout one and a half millenia. His technical advice was sound. His error about the anatomy of blood vessels supplying CNS were not of much consequence since the CNS would remain surgically inaccessible until the end of the 19th century. He reclassified fractures as extending to the diploe or through the internal table. Moreover, they could be simple, comminuted, depressed, or elevated. He did not mention indications or clinical changes, on the other hand he had many sensible remarks to make on the instrumentation required for cranial surgery. As will be seen in what follows, he was much quoted in justification of the decisions of his successors. The major errors of significance related to his description of the anatomy of the cranium and its sutures. His concern about the cranial attachment, vascular components and excretory functions of the sutures added to Hippocrates' concerns about their inherent weakness resulted in the teaching that trepanation should avoid these structures. This was to have a limiting effect on the placement of trepanation openings which was of no benefit to the patients. Moreover, his enthusiasm for bloodletting would also serve to potentiate Hippocrates teaching on this matter, to the advantage of nobody.

Rome-Celsus (ca 25BC to ca. 50AD).

Celsus gave an adequate description of the bones and sutures of the calvarium. His classification of injuries was simple including fissures and depressions. He is the first to relate specific symptoms to specific tissue injury. In addition, he was aware that fractures could be present in the absence of typical findings. He was also the first to note the meningeal vessels could rupture producing severe localized pain. His treatment was more conservative than that of Hippocrates. Plasters were to be used and if there was no deterioration trepanation was avoided. He described the use of the crown trepan (modiolus) and the instrument with a smaller tip which expands rapidly to prevent penetration. He also described the technique of rotating the trepan between the palms. His description of operations for depressed fractures were unusually clear and relevant even by modern standards. His wound care is strikingly different from that of Hippocrates as he advocates various dressings soaked in vinegar and as time passes plasters should be softened with rose oil. Regrettably, Celsus influence would not be felt until the time of the Renaissance, because his texts were lost. However, his "De Medicina" was rediscovered and became the first medical text to be published using the new moveable type printing press, in the year 1478. Thus, his influence was minimal in the Arabic world and the early Renaissance. Thereafter it was profound.