ON INJURIES OF THE
HEAD
by Hippocrates
Translated by Francis
Adams
MEN'S heads are by no means all like to one
another, nor are the
sutures
of the head of all men constructed in the same form. Thus,
whoever
has a prominence in the anterior part of the head (by
prominence
is meant the round protuberant part of the bone which
projects
beyond the rest of it), in him the sutures of the head take
the
form of the Greek letter tau, T; for the head has the shorter line
running
transverse before the prominence, while the other line runs
through
the middle of the head, all the way to the neck. But whoever
has
the prominence in the back part of the head, in him the sutures
are
constructed in quite the opposite form to the former; for in
this
case the shorter line runs in front of the prominence, while
the
longer runs through the middle all along to the forehead. But
whoever
has a prominence of the head both before and behind, in him
the
sutures resemble the Greek letter eta E; for the long lines of the
letter
run transverse before each prominence while the short one
runs
through the middle and terminates in the long lines. But
whoever
has no prominence on either part he has the sutures of the
head
resembling the Greek letter chi; for the one line comes
transverse
to the temple while the other passes along the middle of
the
head. The bone at the middle of the head is double, the hardest
and
most compact part being the upper portion, where it is connected
with
the skin, and the lowest, where it is connected with the meninx
(dura
mater); and from the uppermost and lowermost parts the bone
gradually
becomes softer and less compact, till you come to the
diploe.
The diploe is the most porous, the softest, and most cavernous
part.
But the whole bone of the head, with the exception of a small
portion
of the uppermost and lowermost portions of it, is like a
sponge;
and the bone has in it many juicy substances, like
caruncles;
and if one will rub them with the fingers, some blood
will
issue from them. There are also in the bone certain very
slender
and hollow vessels full of blood. So it is with regard to
hardness,
softness, and porosity.
2. In respect to thickness and thinness; the
thinnest and weakest
part
of the whole head is the part about the bregma; and the bone
there
has the smallest and thinnest covering of flesh upon it, and the
largest
proportion of brain is situated in that region of the head.
And
hence it happens that from similar or even smaller wounds and
instruments,
when a person is wounded to the same or a less degree,
the
bone of the head there is more contused, fractured, and depressed;
and
that injuries there are more deadly and more difficult to cure;
and
it is more difficult to save one's life in injuries there than
in
any other part of the head; that from having sustained a similar or
even
a less wound a man will die, and that, too, in a shorter space of
time
than from a wound in any other part of the head. For the brain
about
the bregma feels more quickly and strongly any mischief that may
occur
to the flesh or the bone; for the brain about the bregma is in
largest
quantity, and is covered by the thinnest bone and the least
flesh.
Of the other portions, the weakest is that about the temples;
for
it is the conjunction of the lower jaw with the cranium, and there
is
motion there up and down as at a joint; and the organ of hearing is
near
it; and further, a hollow and important vein runs along the
temple.
But the whole bone of the head behind the vertex and the ear
is
stronger than the whole anterior part, and the bone itself has a
larger
and deeper covering of flesh upon it. And hence it follows,
that
when exposed to the same or even greater injuries from
instruments
of the same or greater size, the bone is less liable to be
fractured
and depressed than elsewhere; and that in a fatal accident
the
patient will live longer when the wound is in the posterior part
of
the head than when elsewhere; and that pus takes longer time to
form
and penetrate through the bone to the brain, owing to the
thickness
of the bone; and moreover, as there is less brain in that
part
of the head, more persons who are wounded in the back part of the
head
escape than of those who wounded in the anterior part. And in
fatal
cases, a man will survive longer in winter than in summer,
whatever
be the part of the head in which the wound is situated.
3. As to the haedrae (dints or marks?) of sharp
and light weapons,
when
they take place in the bone without fissure, contusion, or
depression
inwards (and these take place equally in the anterior and
posterior
part of the head), death, when it does occur, does not
properly
result from them. A suture appearing in a wound, when the
bone
is laid bare, on whatever part of the head the wound may have
been
inflicted, is the weakest point of the head to resist a blow or a
weapon,
when the weapon happens to be impinged into the suture itself;
but
more especially when this occurs in the bregma at the weakest part
of
the head, and the sutures happen to be situated near the wound, and
the
weapon has hit the sutures themselves.
4. The bone in the head is liable to in the
following modes, and
there
are many varieties in each of these modes of fracture: When a
wounded
bone breaks, in the bone comprehending the fissure,
contusion
necessarily takes place where the bone is broken; for an
instrument
that breaks the bone occasions a contusion thereof more
or
less, both at the fracture and in the parts of the bone surrounding
the
fracture. This is the first mode. But there are all possible
varieties
of fissures; for some of them are fine, and so very fine
that
they cannot be discovered, either immediately after the injury,
or
during the period in which it would be of use to the patient if
this
could be ascertained. And some of these fissures are thicker
and
wider, certain of them being very wide. And some of them extend to
a
greater, and some to a smaller, distance. And some are more
straight,
nay, completely straight; and some are more curved, and that
in
a remarkable degree. And some are deep, so as to extend downwards
and
through the whole bone; and some are less so, and do not penetrate
through
the whole bone.
5. But a bone may be contused, and yet remain
in its natural
condition
without any fracture in it; this is the second mode. And
there
are many varieties of contusion; for they occur to a greater
or
less degree, and to a greater depth, so as sometimes to extend
through
the whole bone; or to a less depth, so as not to extend
through
the whole bone; and to a greater and smaller length and
breadth.
But it is not possible to recognize any of these varieties by
the
sight, so as to determine their form and extent; neither,
indeed,
is it visible to the eyes when any mischief of this kind takes
place,
and immediately after the injury, whether or not the bone has
been
actually bruised, as is likewise the case with certain
fractures
at a distance from the seat of injury.
6. And the bone being fractured, is sometimes
depressed inwards from
its
natural level along with the fractures, otherwise there would be
no
depression; for the depressed portion being fractured and broken
off,
is pushed inwards, while the rest of the bone remains in its
natural
position; and in this manner a fracture is combined with the
depression.
This is the third mode. There are many varieties of
depression,
for it may comprehend a greater and a small extent of
bone,
and may either be to a greater depth, or less so, and more
superficial.
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. 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.
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.
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 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.
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; 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 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 of what assistance it stands in
need.
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.
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 the appearances in the bone,
which
you call 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.
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. 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). 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.
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. 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 surrounding parts. 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 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.
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. 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 commencement. If you suspect that
the
bone is broken or contused, or has sustained both these
injuries,
having formed your judgement 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, and fill
the
wound with it when this 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. 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.
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.
17. Such pieces of bone as are depressed from
their natural
position,
either being broken off or chopped off to a considerable
extent,
are attended with less danger, provided the membrane he
safe;
and bones which are broken by numerous and broader fractures are
still
less dangerous and more easily extracted. And you must not
trepan
any of them, nor run any risks in attempting to extract the
pieces
of bone, until they rise up of their own accord, upon the
subsidence
of the swelling. They rise up when the flesh (granulations)
grows
below, and it grows from the diploe of the bone, and from the
sound
portion, provided the upper table alone be in a state of
necrosis.
And the flesh will shoot up and grow below the more quickly,
and
the pieces of bone ascend, if one will get the wound to
suppurate
and make it clean as quickly as possible. And when both
the
tables of the bone are driven in upon the membrane, I mean the
upper
and lower, the wound, if treated in the same way, will very soon
get
well, and the depressed bones will quickly rise up.
18. The bones of children are thinner and softer,
for this reason,
that
they contain more blood [than those of adults]; and they are
porous
and spongy, and neither dense nor hard. And when wounded to a
similar
or inferior degree by weapons of the same or even of an
inferior
power, the bone of a young person more readily and quickly
suppurates,
and that in less time than the bone of an older person;
and
in accidents, which are to prove fatal, the younger person will
die
sooner than the elder. But if the bone is laid bare of flesh,
one
must attend and try to find out, what even is not obvious to the
sight,
and discover whether the bone be broken and contused, or only
contused;
and if, when there is an indentation in the bone, whether
contusion,
or fracture, or both be joined to it; and if the bone has
sustained
any of these injuries, we must give issue to the blood by
perforating
the bone with a small trepan, observing the greatest
precautions,
for the bone of young persons is thinner and more
superficial
than that of elder persons.
19. When a person has sustained a mortal wound
on the head, which
cannot
be cured, nor his life preserved, you may form an opinion of
his
approaching dissolution, and foretell what is to happen from the
following
symptoms which such a person experiences. When a bone is
broken,
or cleft, or contused, or otherwise injured, and when by
mistake
it has not been discovered, and neither the raspatory nor
trepan
has been applied as required, but the case has been neglected
as
if the bone were sound, fever will generally come on if in
winter,
and in summer the fever usually seizes after seven days. And
when
this happens, the wound loses its color, and the inflammation
dies
in it; and it becomes glutinous, and appears like a pickle, being
of
a tawny and somewhat livid color; and the bone then begins to
sphacelate,
and turns black where it was white before, and at last
becomes
pale and blanched. But when suppuration is fairly
established
in it, small blisters form on the tongue and he dies
delirious.
And, for the most part, convulsions seize the other side of
the
body; for, if the wound be situated on the left side, the
convulsions
will seize the right side of the body; or if the wound
be
on the right side of the head, the convulsion attacks the left side
of
the body. And some become apoplectic. And thus they die before
the
end of seven days, if in summer; and before fourteen, if in
winter.
And these symptoms indicate, in the same manner, whether the
wound
be older or more recent. But if you perceive that fever is
coming
on, and that any of these symptoms accompany it, you must not
put
off, but having sawed the bone to the membrane (meninx), or
scraped
it with a raspatory (and it is then easily sawed or
scraped),
you must apply the other treatment as may seem proper,
attention
being paid to circumstances.
20. When in any wound of the head, whether
the man has been
trepanned
or not, but the bone has been laid bare, a red and
erysipelatous
swelling supervenes in the face, and in both eyes, or in
either
of them, and if the swelling be painful to the touch, and if
fever
and rigor come on, and if the wound look well, whether as
regards
the flesh or the bone, and if the parts surrounding the
wound
be well, except the swelling in the face, and if the swelling be
not
connected with any error in the regimen, you must purge the bowels
in
such a case with a medicine which will evacuate bile; and when thus
purged
the fever goes off, the swelling subsides, and the patient gets
well.
In giving the medicine you must pay attention to the strength of
the
patient.
21. With regard to trepanning, when there is
a necessity for it, the
following
particulars should be known. If you have had the
management
of the case from the first, you must not at once saw the
bone
down to the meninx; for it is not proper that the membrane should
be
laid bare and exposed to injuries for a length of time,as in the
end
it may become it may become fungous. And and there is another
danger
if you saw the bone down to the meninx and remove it at once,
lest
in the act of sawing you should wound the meninx. But in
trepanning,
when only a very little of the bone remains to be sawed
through,
and the bone can be moved, you must desist from sawing, and
leave
the bone to fall out of itself. For to a bone not sawed through,
and
where a portion is left of the sawing, no mischief can happen; for
the
portion now left is sufficiently thin. In other respects you
must
conduct the treatment as may appear suitable to the wound. And in
trepanning
you must frequently remove the trepan, on account of the
heat
in the bone, and plunge it in cold water. For the trepan being
heated
by running round, and heating and drying the bone, burns it and
makes
a larger piece of bone around the sawing to drop off, than would
otherwise
do. And if you wish to saw at once down to the membrane, and
then
remove the bone, you must also, in like manner, frequently take
out
the trepan and dip it in cold water. But if you have not charge of
the
treatment from the first, but undertake it from another after a
time,
you must saw the bone at once down to the meninx with a serrated
trepan,
and in doing so must frequently take out the trepan and
examine
with a sound (specillum), and otherwise along the tract of the
instrument.
For the bone is much sooner sawn through, provided there
be
matter below it and in it, and it often happens that the bone is
more
superficial, especially if the wound is situated in that part
of
the head where the bone is rather thinner than in other parts.
But
you must take care where you apply the trepan, and see that you do
so
only where it appears to be particularly thick, and having fixed
the
instrument there, that you frequently make examinations and
endeavor
by moving the bone to bring it up. Having removed it, you
must
apply the other suitable remedies to the wound. And if, when
you
have the management of the treatment from the first, you wish to
saw
through the bone at once, and remove it from the membrane, you
must,
in like manner, examine the tract of the instrument frequently
with
the sound, and see that it is fixed on the thickest part of the
bone,
and endeavor to remove the bone by moving it about. But if you
use
a perforator (trepan?), you must not penetrate to the membrane, if
you
operate on a case which you have had the charge of from the first,
but
must leave a thin scale of bone, as described in the process of
sawing.
-THE END-
