The genuine works of Hippocrates, Vol. 1 (of 2)

by Hippocrates

7. When a hedra, or dint of a weapon, takes place in a bone, there may be a fracture combined with it; and provided there be a fracture, contusion must necessarily be joined, to a greater or less extent, in the seat of the dint and fracture, and in the bone which comprehends them.[789] This is the fourth mode. And there may be a hedra, or indentation of the bone, along with contusion of the surrounding bone, but without any fracture either in the hedra or in the contusion inflicted by the weapon. But the indentation of a weapon takes place in a bone, and is called hedra, when the bone remaining in its natural state, the weapon which struck against the bone leaves its impression on the part which it struck. In each of these modes there are many varieties, with regard to the contusion and fracture, if both these be combined with the hedra, or if contusion alone, as it has been already stated that there are many varieties of contusion and fracture. And the hedra, or dint, of itself may be longer and shorter, crooked, straight, and circular; and there are many varieties of this mode, according to the shape of the weapon; and they may be more or less deep, and narrower or broader, and extremely broad. When a part is cleft, the cleft or notch which occurs in the bone, to whatever length or breadth, is a hedra, if the other bones comprehending the cleft remain in their natural position, and be not driven inwards; for in this case it would be a depression, and no longer a hedra.[790]

8. A bone may be injured in a different part of the head from that on which the person has received the wound, and the bone has been laid bare. This is the fifth mode. And for this misfortune, when it occurs, there is no remedy; for when this mischief takes place, there is no means of ascertaining by any examination whether or not it has occurred, or on what part of the head.[791]

9. Of these modes of fracture, the following require trepanning: the contusion, whether the bone be laid bare or not; and the fissure, whether apparent or not. And if, when an indentation (hedra) by a weapon takes place in a bone it be attended with fracture and contusion, and even if contusion alone, without fracture, be combined with the indentation, it requires trepanning. A bone depressed from its natural position rarely requires trepanning; and those which are most pressed and broken require trepanning the least; neither does an indentation (hedra) without fracture and contusion require trepanning; nor does a notch, provided it is large and wide; for a notch and a hedra are the same.[792]

10. In the first place, one must examine the wounded person, in what part of the head the wound is situated, whether in the stronger or weaker parts; and ascertain respecting the hairs about the wound, whether they have been cut off by the instrument, and have gone into the wound; and if so, one should declare that the bone runs the risk of being denuded of flesh, and of having sustained some injury from the weapon. These things one should say from a distant inspection, and before laying a hand on the man;[793] but on a close examination one should endeavor to ascertain clearly whether the bone be denuded of flesh or not; and if the denuded bone be visible to the eyes, this will be enough; but otherwise an examination must be made with the sound. And if you find the bone denuded of the flesh, and not safe from the wound, you must first ascertain the state of the bone, and the extent of the mischief, and what assistance it stands in need of. One should also inquire of the wounded person how and in what way he sustained the injury; and if it be not apparent whether the bone has sustained an injury or not, it will be still more necessary, provided the bone be denuded, to make inquiry how the wound occurred, and in what manner; for when contusions and fractures exist in the bone, but are not apparent, we must ascertain, in the first place from the patient’s answers, whether or not the bone has sustained any such injuries, and then find out the nature of the case by word and deed, with the exception of sounding. For sounding does not discover to us whether the bone has sustained any of these injuries or not; but sounding discovers to us an indentation inflicted by a weapon, and whether a bone be depressed from its natural position, and whether the bone be strongly fractured; all which may also be ascertained visibly with the eyes.[794]

11. And a bone sustains fractures, either so fine as to escape the sight, or such as are apparent, and contusions which are not apparent, and depression from its natural position, especially when one person is intentionally wounded by another, or when, whether intentionally or not, a blow or stroke is received from an elevated place, and if the instrument in the hand, whether used in throwing or striking, be of a powerful nature, and if a stronger person wound a weaker. Of those who are wounded in the parts about the bone, or in the bone itself, by a fall, he who falls from a very high place upon a very hard and blunt object is in most danger of sustaining a fracture and contusion of the bone, and of having it depressed from its natural position; whereas he that falls upon more level ground, and upon a softer object, is likely to suffer less injury in the bone, or it may not be injured at all. Of those instruments which, falling upon the head, wound the parts about the bone, or the bone itself, that which falls from a very high place, and the least on a level with the person struck, and which is at the same time very hard, very blunt, and very heavy, and which is the least light, sharp, and soft, such an instrument would occasion a fracture and contusion of the bone. And there is most danger that the bone may sustain these injuries, under such circumstances, when the wound is direct and perpendicular to the bone, whether struck from the hand or from a throw, or when any object falls upon the person, or when he is wounded by falling, or in whatever way the bone sustains a direct wound from this instrument. Those weapons which graze the bone obliquely are less apt to fracture, contuse, or depress the bone, even when the bone is denuded of flesh; for in some of those wounds thus inflicted the bone is not laid bare of the flesh. Those instruments more especially produce fractures in the bone, whether apparent or not, and contusions, and inward depression of the bone, which are rounded, globular, smooth on all sides, blunt, heavy, and hard; and such weapons bruise, compress, and pound the flesh; and the wounds inflicted by such instruments, whether obliquely or circularly, are round, and are more disposed to suppurate, and to have a discharge, and take longer time to become clean; for the flesh which has been bruised and pounded must necessarily suppurate and slough away. But weapons of an oblong form, being, for the most part, slender, sharp, and light, penetrate the flesh rather than bruise it, and the bone in like manner; and such an instrument may occasion a hedra and a cut (for a hedra and a cut are same thing); but weapons of this description do not produce contusions, nor fractures, nor depressions inwardly. And in addition to the appearances in the bone, which you can detect by the sight, you should make inquiry as to all these particulars (for they are symptoms of a greater or less injury), whether the wounded person was stunned, and whether darkness was diffused over his eyes, and whether he had vertigo, and fell to the ground.[795]

12. When the bone happens to be denuded of flesh by the weapon, and when the wound occurs upon the sutures, it is difficult to distinguish the indentation (hedra) of a weapon which is clearly recognized in other parts of the bone, whether it exist or not, and especially if the hedra be seated in the sutures themselves. For the suture being rougher than the rest of the bone occasions confusion, and it is not clear which is the suture, and which the mark inflicted by the instrument, unless the latter (hedra) be large. Fracture also for the most part is combined with the indentation when it occurs in the sutures; and this fracture is more difficult to discern when the bone is broken, on this account, that if there be a fracture, it is situated for the most part in the suture. For the bone is liable to be broken and slackened there, owing to the natural weakness of the bone there, and to its porosity, and from the suture being readily ruptured and slackened: but the other bones which surround the suture remain unbroken, because they are stronger than the suture.[796] For the fracture which occurs at the suture is also a slackening of the suture, and it is not easy to detect whether the bone be broken and slackened by the indentation of a weapon occurring in the suture, or from a contusion of the bone at the sutures; but it is still more difficult to detect a fracture connected with contusion. For the sutures, having the appearance of fissures, elude the discernment and sight of the physician, as being rougher than the rest of the bone, unless the bone be strongly cut and slackened, (for a cut and a hedra are the same thing.)[797] But it is necessary, if the wound has occurred at the sutures, and the weapon has impinged on the bone or the parts about it, to pay attention and find out what injury the bone has sustained. For a person wounded to the same, or a much smaller, extent, and by weapons of the same size and quality, and even much less, will sustain a much greater injury, provided he has received the blow at the sutures, than if it was elsewhere. And many of these require trepanning, but you must not apply the trepan to the sutures themselves, but on the adjoining bone.[798]

13. And with regard to the cure of wounds in the head, and the mode of detecting injuries in the bone which are not apparent, the following is my opinion:—In a wound of the head, you must not apply anything liquid, not even wine, but as little as possible, nor a cataplasm, nor conduct the treatment with tents, nor apply a bandage to an ulcer on the head, unless it be situated on the forehead, in the part which is bare of hairs, or about the eyebrow and eye, for wounds occurring there require cataplasms and bandages more than upon any other part of the head.[799] For the rest of the head surrounds the whole forehead, and the wounds wherever situated become inflamed and swelled, owing to an influx of blood from the surrounding parts.[800] And neither must you apply cataplasms and bandages to the forehead at all times; but when the inflammation is stopped and the swelling has subsided, you must give up the cataplasms and bandages. A wound in any other part of the head must not be treated with tents, bandages, or cataplasms, unless it also requires incision. You must perform incision on wounds situated on the head and forehead, whenever the bone is denuded of flesh, and appears to have sustained some injury from the blow, but the wound has not sufficient length and breadth for the inspection of the bone, so that it may be seen whether it has received any mischief from the blow, and of what nature the injury is, and to what extent the flesh has been contused, and whether the bone has sustained any injury, or whether it be uninjured by the blow, and has suffered no mischief; and with regard to the treatment, what the wound, and the flesh, and the injury of the bone stand in need of. Ulcers of this description stand in need of incision; and, if the bone be denuded of the flesh, and if it be hollow, and extend far obliquely, we cut up the cavity wherever the medicine cannot penetrate readily, whatever medicine it may be; and wounds which are more inclined to be circular and hollow, and for the most part others of the like shape, are cut up by making a double incision in the circle lengthways, according to the figure of the man, so as to make the wound of a long form. Incisions may be practiced with impunity on other parts of the head, with the exception of the temple and the parts above it, where there is a vein that runs across the temple, in which region an incision is not to be made. For convulsions seize on a person who has been thus treated; and if the incision be on the left temple, the convulsions seize on the right side; and if the incision be on the right side, the convulsions take place on the left side.[801]

14. When, then, you lay open a wound in the head on account of the bones having been denuded of the flesh, as wishing to ascertain whether or not the bone has received an injury from the blow, you must make an incision proportionate to the size of the wound, and as much as shall be judged necessary. And in making the incision you must separate the flesh from the bone where it is united to the membrane (pericranium?) and to the bone, and then fill the whole wound with a tent, which will expand the wound very wide next day with as little pain as possible; and along with the tents apply a cataplasm, consisting of a mass (maza) of fine flour pounded in vinegar, or boiled so as to render it as glutinous as possible.[802] On the next day, when you remove the tent, having examined the bone to see what injury it has sustained, if the wound in the bone be not right seen by you, nor can you discover what mischief the bone itself has sustained, but the instrument seems to have penetrated to the bone so as to have injured it, you must scrape the bone with a raspatory to a depth and length proportionate to the suture of the patient, and again in a transverse direction, for the sake of the fractures which are not seen, and of the contusions which are not discovered, as not being accompanied with depression of the bone from its natural position. For the scraping discovers the mischief, if the injuries in the bone be not otherwise manifest. And if you perceive an indentation (hedra) left in the bone by the blow, you must scrape the dint itself and the surrounding bones, lest, as often happens, there should be a fracture and contusion, or a contusion alone, combined with the dint, and escape observation. And when you scrape the bone with the raspatory, and it appears that the wound in the bone requires the operation, you must not postpone it for three days, but do it during this period, more especially if the weather be hot, and you have had the management of the treatment from the commencement. If you suspect that the bone is broken or contused, or has sustained both these injuries, having formed your judgment from the severity of the wound, and from the information of the patient, as that the person who inflicted the wound, provided it was done by another person, was remarkably strong, and that the weapon by which he was wounded was of a dangerous description, and then that the man had been seized with vertigo, dimness of vision, and stupor, and fell to the ground,—under these circumstances, if you cannot discover whether the bone be broken, contused, or both the one and the other, nor can see the truth of the matter, you must dissolve the jet-black ointment,[803] and fill the wound with it when thus dissolved, and apply a linen rag smeared with oil, and then a cataplasm of the maza with a bandage; and on the next day, having cleaned out the wound, scrape the bone with the raspatory. And if the bone is not sound, but fractured and contused, the rest of it which is scraped will be white; but the fracture and contusion, having imbibed the preparation, will appear black, while the rest of the bone is white. And you must again scrape more deeply the fracture where it appears black; and, if you thus remove the fissure, and cause it to disappear, you may conclude that there has been a contusion of the bone to a greater or less extent, which has occasioned the fracture that has disappeared under the raspatory; but it is less dangerous, and a matter of less consequence, when the fissure has been effaced. But if the fracture extend deep, and do not seem likely to disappear when scraped, such an accident requires trepanning. But having performed this operation, you must apply the other treatment to the wound.

15. You must be upon your guard lest the bone sustain any injury from the fleshy parts if not properly treated. When the bone has been sawed and otherwise denuded, whether it be actually sound, or only appears to be so, but has sustained some injury from the blow, there may be danger of its suppurating (although it would not otherwise have done so), if the flesh which surrounds the bone be ill cured, and become inflamed and strangled; for it gets into a febrile state, and becomes much inflamed.[804] For the bone acquires heat and inflammation from the surrounding flesh, along with irritation and throbbing, and the other mischiefs which are in the flesh itself, and from these it gets into a state of suppuration. It is a bad thing for the flesh (granulations?) in an ulcer to be moist and mouldy, and to require a long time to become clean. But the wound should be made to suppurate as quickly as possible; for, thus the parts surrounding the wound would be the least disposed to inflammation, and would become the soonest clean; for the flesh which has been chopped and bruised by the blow, must necessarily suppurate and slough away. But when cleaned the wound must be dried, for thus the wound will most speedily become whole, when flesh devoid of humors grows up, and thus there will be no fungous flesh in the sore. The same thing applies to the membrane which surrounds the brain: for when, by sawing the bone, and removing it from the meninx, you lay the latter bare, you must make it clean and dry as quickly as possible, lest being in a moist state for a considerable time, it become soaked therewith and swelled; for when these things occur, there is danger of its mortifying.[805]

16. A piece of bone that must separate from the rest of the bone, in consequence of a wound in the head, either from the indentation (hedra) of a blow in the bone, or from the bone being otherwise denuded for a long time, separates mostly by becoming exsanguous. For the bone becomes dried up and loses its blood by time and a multiplicity of medicines which are used; and the separation will take place most quickly, if one having cleaned the wound as quickly as possible will next dry it, and the piece of bone, whether larger or smaller. For a piece of bone which is quickly dried and converted, as it were, into a shell, is most readily separated from the rest of the bone which retains its blood and vitality; for, the part having become exsanguous and dry, more readily drops off from that which retains its blood and is alive.[806]