interesting to examine the solution of it attempted by authorities
who lived about the period when the original study of human anatomy
was revived in modern times. In the first place, then, I may mention
that Ambrose Paré, who, I need scarcely say, was possessed of no mean
talent for original observation, in treating of fractures of the
head, adopts exactly the description given by Hippocrates; thus he
describes “the bunches of the head” in nearly the same terms as our
author, and adds, that such “bunches change the figure and site of
the sutures,” and that “there be some skulls that want the foremost
suture, and other some the hind, and sometimes none of the true
sutures, but only the false, _or_ spurious, remain.”[752] Nay,
it. cannot but appear remarkable, that Vesalius, the great antagonist
of Galen and of the ancient authorities in general, in the present
instance does not venture to call in question their opinion, but gives
a description of the different forms of the head, and the varieties
of the sutures, which scarcely at all differs from that given by
Hippocrates.[753] It is singular, also, that certain other authorities,
who were much more disposed to show a leaning to antiquity, such as
Columbus, Eustachius, Fallopius, and Riolanus, should, in the present
instance, have manifested a more independent spirit in challenging
the authority of Hippocrates, though, at the same time, they show a
disposition to find out some mode of bringing him clear off. Thus, for
example, Riolanus is compelled to admit that there is no such variety
in the forms and numbers of the sutures as Hippocrates describes;
but he attempts to free him from error, by suggesting that the cases
in which Hippocrates found them wanting must have been those of old
men.[754] He also quotes some very extraordinary instances, in which
something approaching the varieties described by our author had been
remarked.[755] Fallopius does not hesitate, in his great anatomical
work, to express the surprise he felt that all the authorities should
have assented to the descriptions of the protuberances and sutures
of the head given by Hippocrates; for that he, after having examined
large heaps of crania in the Musea of Ferrara and Florence, had not
found that they agreed with the descriptions given by Hippocrates;
that he had seen crania without a suture, and yet not wanting in the
protuberances; and in like manner, that he had seen the coronal suture
obliterated, and yet the skull possessed its anterior prominence,
and the lambdoid wanting, although the posterior protuberance was as
usual. Altogether, then, in this work he modestly ventures to impugn
the authority of Hippocrates.[756] In his work entitled “Expositio in
Librum Galeni de Ossibus,” he adopts the same views, and there declares
that he had never seen the sutures obliterated except from old age.
But, in his work entitled “Expositio in Lib. Hippocrat. de Vulneribus
Capitis,” he gives two suppositions, which he had devised in order to
defend the authority of Hippocrates: first, that Hippocrates did not
give these varieties of form as real, but as hypothetical; and second,
that he merely described them as being the vulgar opinion, without
pledging himself to the correctness of the description. These, as far
as I am aware, are the only defences which have ever been set up for
our author in this matter, and it must be admitted that they are not
very satisfactory. I shall now present the reader with the conjectural
explanation which has occurred to myself. I have imagined that what
Hippocrates meant was to express himself to the following effect:
when the forehead is remarkably prominent, and, at the same time,
there is a great depression behind, the cranium, if looked upon from
above, will show the coronal suture running across the fore part of
the head, and the sagittal through its middle, while the lambdoid will
be inconspicuous, from being below the level of the coronal. The two
together, then, would form some resemblance to the letter T. When, on
the other hand, the forehead is low, that is to say, wants its normal
development, and the occiput is unusually prominent, the lambdoid
suture joins the sagittal, so as to present some appearance of the same
letter reversed. But in a square-built head, where the frontal and
occipital regions have protuberances equally developed, the coronal and
lambdoid sutures run nearly parallel to one another, and are joined
in the middle by the sagittal, in which case the three sutures may be
imagined to present some resemblance to the Greek letter Η. When there
is no protuberance either before or behind, and the sagittal suture
passes through the middle of the bone down to the nasal process, the
coronal suture intersects it, so as to give them something like the
shape of the Greek letter χ.[757] I offer this explanation, however,
merely as a conjecture, and wish the reader to judge of it accordingly.
I now proceed to give an analysis of the contents of this treatise, and
to attempt to form a correct estimate of their value.
Injuries of the cranial bones are divided by our author into five
orders, as follows: 1, simple fractures, _or_ fissures of various kinds
and sizes (§ 4); 2, contusion, without fracture or depression (§ 5);
3, fractures attended with depression (§ 6); 4, the _hedra_, that is
to say, the indentation or cut in the outer table of the bone, and not
necessarily attended either with fracture or contusion (§ 7); 5, the
counter-fissure, or _fracture par contre-coup_ fracture and the severe
contusion, require the operation of trepanning; whereas neither the
_hedra_ (_or_ simple cut) nor the depressed fracture require it, and
the counter-fissure does not admit it, owing to the obscurity of the
symptoms with which it is attended (§ 9).
In the first place, the surgeon is to ascertain the nature and
situation of the wound, by a careful investigation of all the
circumstances of the case, but so as to avoid the use of the sound, if
possible (§§ 9, 10).
Next are described the various kind of injury which the different sorts
of weapons are most likely to inflict, and from the consideration of
them the surgeon is to form an estimate of the probable nature of the
accident (§ 11).
The characters of the _hedra_, or superficial injury of the
cranium, and the difficulty of forming a correct estimate of it, when
complicated by the presence of a suture, are strongly insisted upon (§
12).
The principles upon which the treatment of injuries situated in
different parts of the head should be treated, are carefully defined
and stated. Great, and as now would be thought, superfluous directions
are given, for ascertaining whether or not a fissure exists in the
bone. The treatment, as far as applications go, is to be mild and
desiccant. When a fracture cannot be made to disappear by scraping, the
trepan is to be applied (§§ 13, 14).
The dangers which the bone incurs of becoming affected from the soft
parts, are strongly insisted upon, and applications of a drying nature
are prescribed (§ 15).
The condition of a piece of bone which is going to exfoliate is
correctly and strikingly described (§ 16).
The treatment of depression is laid down, and the danger of applying
the trepan in this case is strongly insisted upon (§ 17).
The peculiarities in the case of children are pointed out. Under
certain circumstances, when there is contusion combined with the
fracture, he admits of perforating the skull with a small trepan (§ 18).
When, after a severe injury, symptoms of irritation and inflammation
appear to be coming on, the surgeon is to lose no time in proceeding to
the operation. Some correct observations are made on the consequences
of injuries of the head on other parts of the body (§ 19).
The treatment of erysipelatous inflammation is distinctly laid down
(§20).
The operation of trepanning the skull is circumstantially described,
and an interesting description is given of a mode of doing the
operation peculiar to our author[758] (§ 21).
This, then, as far as I know, is the first exposition ever made of a
highly important subject in surgery, upon which professional men are
still greatly divided in opinion. I cannot, then, resist the temptation
to offer some remarks on the views of practice here recommended, and to
institute a comparison between them and certain methods of treatment
which have been in vogue of late years.
I can scarcely doubt but it will be generally admitted that the
exposition of the subject here given is remarkably lucid, that
our author’s divisions of it are strongly marked, and his rules
of practice, whether correct or not, distinctly laid down. At all
events, it will not be affirmed that there is any confusion in his
ideas, or that his principles of treatment are not properly defined.
After all that has been written on injuries of the head, it would be
difficult to point to any better arrangement of them than that of our
author, into five orders: 1st, simple fractures without depression;
2d, contusions without fracture or depression; 3d, depression with
fracture; 4th, simple incisions without fracture; 5th, fractures _par
contre-coup_.
As regards the operation of trepanning the skull, then, our author’s
rule of practice is sufficiently well defined: we are to operate in
the first two of these cases, that is to say, in simple fractures and
contusions, but not in the last three, that is to say, in fracture
with depression, in simple incisions in the skull, and in the
counter-fissure. To begin, then, with the examination of those cases in
which the operation is proscribed: it is not to be had recourse to in
the counter-fissure, because, from the nature of it, there is generally
no rule by which its existence can be positively ascertained, and
therefore the case is to be given up as hopeless.
In the simple incision of the bone, that is to say, in the slash or
indentation, when the effects of the injury are not transmitted to the
brain, it must be obvious that all instrumental interference must be
strongly contraindicated.[759]
At first sight it will appear remarkable to a surgeon, who approaches
the subject with views exclusively modern, that our author should have
interdicted the use of instruments in that class of injuries in which
one would be inclined to suppose that they are most clearly indicated,
namely, in a fracture of considerable extent, attended with depression
of part of the bone from its natural level. Several questions present
themselves here to be solved. Is the operation generally required? Has
it been successful when it has been had recourse to? When it is to be
performed, should it be done immediately, or not until the bad effects
of the injury have manifested themselves?
With regard, then, to the necessity of the operation for depressed
fractures, the most discordant opinions have prevailed in modern times,
and even within a very recent period. Not to go farther back than
Pott, it is well known that he established it as the general rule of
practice, that in every case of fracture with depression, the skull
should be perforated, and the depressed portion of the bone either
raised to its level, or entirely removed. But since his time a great
change of opinion has taken place on this subject, and of late it
has become the general rule of practice (if rule can be predicated,
where opinions are so vague and indeterminate) not to interfere, even
in cases of depression, unless urgent symptoms have supervened. The
late Mr. Abernethy took the lead in questioning the propriety of the
rule laid down by Pott; and with the view of demonstrating that the
operation may be often dispensed with in fractures complicated with
depression, and in order, as he says, “to counteract in some degree
the bias which long-accustomed modes of thinking and acting are apt to
impress on the minds of practitioners,” he relates the histories of
five cases of fracture with depression, which, in the space of twelve
months, occurred under his own eyes in St. Bartholomew’s Hospital, and
which all terminated favorably, although no operation was performed.
These cases, supported by the authority of so great a name as Mr.
Abernethy, made a deep impression on the profession, especially in
this country, so that it became the established rule of practice in
British surgery never to interfere in cases of fracture, unless with
the view of removing urgent symptoms. See Cooper’s Surgical Dictionary,
edit. 1825, and the previous edition. The old Hippocratic rule in
regard to the trepan, when it is at all to be applied, namely, that
of applying it as a preventive of bad consequences, was altogether
eschewed, and it was held to be perfectly unwarrantable to perforate
the skull, except with the intention of removing substances which were
creating irritation and pressure of the brain. This practice, I say,
was sanctioned by all the best army and hospital surgeons, from about
the beginning of the present century, down to a very recent period.
What, then, it will be asked, have been the results? Has experience
confirmed the safety of this rule of practice, or has it not? To enable
us to solve these queries, we have most elaborate and trustworthy
statistics, published a few years ago by Dr. Laurie of Glasgow, which
deserve to be seriously studied by every surgeon who may be called
upon to discharge the duties of his profession in such cases. I cannot
find room for long extracts from these valuable papers, but may be
allowed to state a few of the more important results which are to be
deduced from Dr. Laurie’s interesting investigation. Coming then at
once to the point, it deserves to be remarked that Dr. Laurie’s ample
experience has led him to reject decidedly the rule of practice,
which, as I have stated, was established by Mr. Abernethy, about
forty years ago, namely, that, in cases of depression, the symptoms
of compression should be our guide to the employment of the trephine.
He adds, “however well this rule may sound, when delivered _ex
cathedrá_, it will be found of very little practical utility, for
this reason, that if we limit interference to cases exhibiting symptoms
of compression, we had much better not interfere at all, inasmuch as
such cases prove almost invariably fatal. Such, at least, has been
the experience of the Glasgow hospitals; for out of fifty-six cases
operated upon, including, in point of time, a period little short of
fifty years, there does not appear in our records a single unequivocal
instance of profound insensibility, in which the mere operation of
trepanning removed the coma and paralysis, or in any way conduced
to the recovery of the patient. We wish to be clearly understood as
speaking of the trephine used in reference to the state of the bone in
cases of profound insensibility, not employed to remove extravasated
blood. Nor does the cause of our want of success appear at all obscure.
We believe that in practice the cases of urgent compression dependent
on depressed bone alone are very few indeed; we are well aware that
many such are on record, we do not presume to impugn their accuracy, we
merely affirm that the records of the Glasgow Infirmary do not add to
the number.” He thus states his views with regard to the principles by
which the application of the trephine should be regulated. “From what
we have said, it will appear that we coincide with these who, in using
the trephine, in cases of compound fracture of the skull, look more to
the state of the bone than to the general symptoms, and _who employ
it more as a preventive of inflammation and its consequences, than as
a cure for urgent symptoms, the immediate result of the accident_.”
He goes on to state that “the details we have given are by no means
in favor of the trephine. Of fifty-six cases operated upon, eleven
recovered, and forty-five died. We feel assured that this affords too
favorable a view of the actual results.”[760]
* * * * *
From the extracts now given, it will readily be seen that this very
able authority has rejected entirely the rule of practice established
by Mr. Abernethy, and that, in so far, he has reverted to the principle
upon which the use of the instruments in simple fractures of the
skull was regulated by Hippocrates, namely, as a preventive of the
bad consequences of fracture on the brain, rather than with the view
of relieving them when established. It will further be seen that, in
whatever way applied, the use of perforating instruments in the case of
depressed fractures is attended with so unsatisfactory results, that
it may be doubted if any other operation in surgery, recognized as
legitimate, be equally fatal.[761] Less than one fifth of the patients
operated upon recovered. In fact, he very candidly admits “that it
would not have been greatly to the disadvantage of the patients
admitted into the Glasgow Infirmary, if the trephine had never found
its way within its walls.” He further, in conclusion, adverts to the
well-known fact that Desault, in the end, completely abandoned the
operation, and that Mr. Lawrence states, “as far as the experience of
this Hospital (St. Bartholomew’s) goes, he can cite very few instances
in which the life of the patient had been saved by the operation of
trephining.”[762]
Altogether, then, it will be allowed to no very questionable
whether, in general, the Hippocratic treatment, in cases of fracture
with depression, would not be fully as successful as the modern
practice of perforating the skull. Moreover, it is by no means well
ascertained, as generally assumed by superficial observers of facts
in medical practice, that depressed fractures are more dangerous than
other injuries of the skull attended with less formidable appearances.
Indeed, recent experience has shown, in confirmation of the opinion
advanced by our author, that extensive fractures, with great
depression, are frequently not followed by any very dangerous train
of consequences. (See Thomson’s “Observations made in the Military
Hospitals of Belgium,” pp. 59, 60; Hennen’s “Military Surgery,” p. 287;
Cooper’s “Lectures,” xiii.; Mr. Guthrie’s “Lectures on Injuries of the
Head,” p. 56.) All these, in substance, coincide with Mr. Guthrie, who
mentions with approbation that “it has been stated from the earliest
antiquity, that the greater the fracture, the less the concussion
of the brain.” I may mention further, that I myself, in the course
of my own experience, have known many instances in which fractures
with considerable depression were not followed, either immediately
or afterwards, by any bad consequences; while, on the other hand,
I have known cases in which simple contusion of the bone, without
fracture or extravasation, and without even very urgent symptoms of
concussion at first, have proved fatal in the course of a day or two.
Now, in such circumstances, Hippocrates would have operated by either
perforating the skull at once, down to the meninx, and removing a
piece of it, or by sawing it nearly through, and leaving the piece of
bone to exfoliate. It will be asked here, what object can he have had
in view by this procedure? This he has nowhere distinctly defined;
but, judging from the whole tenor of this treatise, and that of his
commentator, Galen, I can have no doubt in my mind that what he wished
to accomplish was to loosen the bones of the head, and give greater
room to the brain, which he conceived to be in a state of congestion
and swelling brought on by the vibration, or _trémoussement_,
communicated directly to the brain by the contusion. It is, in fact, an
opinion which Hippocrates repeatedly inculcates, not only with regard
to the brain, but also respecting injuries of the chest and joints,
that severe contusions are, in general, more dangerous than fractures,
the effects of the vibration in the former case being more violent than
in the latter.[763] Believing, then, that, in contusions, the internal
structure of the brain is extensively injured, and that irritation,
with hypertrophy, are the consequences, he advocated instrumental
interference, in order as I have stated, to give more room to the
brain, and relieve it from its state of compression.[764] This, no
doubt, was the rationale of his practice also in simple fractures, not
attended with depression, that is to say, his object in perforating the
skull was to remove tension, and furnish an outlet to the collection
within, whether of a liquid or a gaseous nature.
There can be no doubt that our author also had it in view, by
perforating the skull, to afford an issue to extravasated blood and
other matters collected within the cranium. This clearly appears
from what is stated in section 18, and the same rule of practice is
distinctly described by Celsus in the following terms: “Raro, sed
aliquando tamen evenit, ut os quidem totum integrum maneat, intus
vero ex ictu vena aliqua in cerebri membrana rupta aliquid sanguinis
mittat; isque ibi concretus magnos dolores moveat, et oculos quibusdam
obcæcet.... Sed ferè contra id dolor est, et, eo loco cute incisa,
pallidum os reperitur: ideoque id os quoque excidendum est.” (viii.,
4.) It is quite certain, then, that one of the objects for which our
author recommended trepanning, was to give issue to extravasated blood
on the surface of the skull. This naturally leads me to compare the
results of modern experience in the treatment of cases of contusion,
with or without extravasation of blood.
All the earlier of our modern authorities on surgery, such as
Theodoric, Pet. c. Largelata, Ambrose Paré, Wiseman, and Fallopius,
distinctly held that contusions of the skull, even when not complicated
with a fracture, are often of so formidable a nature as to require
the use of perforating instruments. The same views are strenuously
advocated by Pott, who has described the effects of contusion in very
elegant and impressive language. See page 42; ed. Lond. 1780. The
upshot is, that one of the consequences of a severe contusion of the
bone frequently is separation of the pericranium, “which is almost
always followed by a separation between the cranium and the dura
mater; a circumstance extremely well worth attending to in fissures
and undepressed fractures of the skull, because it is from this
circumstance principally that the bad symptoms and the hazard in such
cases arise.” (p. 50.)[765] After insisting, in very strong terms, on
the danger attending severe contusions of the, skull, he proceeds to
lay down the rules of treatment, which, in a word, are comprehended
in the two following intentions:--first, to prevent bad consequences
by having recourse, at first, to depletion; and, second, to procure
the discharge of matter collected under the cranium, which can be
answered only by the perforation of it. He agrees with Archigenes that
the operation is generally too long deferred, and that the sooner it
is performed the better. Still, however, it is to be borne in mind
that even Potts does not make it a general rule to operate at first,
_before_ the bad symptoms have come on, that is to say, during the
first three days, and that he rather appears to have followed Celsus,
who alludes to the method of Hippocrates, and describes his rule of
practice in the following terms:
--“In omni vero fisso fractoque osse, protinus antiquiores medici
ad ferramenta veniebant, quibus id exciderent. Sed multo melius est
ante emplastra experiri, etc.... Si vero sub prima curatione febris
intenditur, ... magni dolores sunt, cibique super hæc fastidium
increseit; tum demum ad manum scalprumque veniendum est.” (viii., 4.)
Pott then, it appears, follows the rule of Celsus, and does not operate
until unpleasant effects have developed themselves;[766] but, at the
same time, he candidly admits that, although the course now described
be all that our art is capable of doing in these melancholy cases,
he wishes he could say that it was frequently successful. He then
goes on to relate several cases: first, of simple contusion without
a wound; second, of contusion with a wound; and, third, of contusion
with extravasation. In all these classes of cases he operated with
very equivocal results; but then it is to be borne in mind, that, as
I have said, he operated, like Celsus, after the bad effects had come
on, and not, like Hippocrates, at first, in order to prevent them.
Even with all these discouraging results, he continued to adhere to
this rule of treatment, which, under the sanction of his name, became
the established practice of the profession. The late Mr. Abernethy,
who took the lead in innovating upon Pott’s rules for the application
of the trephine, did not venture to make any material change in this
case when he supposed that there was any considerable extravasation of
blood; and he delivered it as a test whereby we might judge whether
or not a great vessel had been ruptured within the skull, to examine
whether or no the bone bled, having generally found, as, indeed, had
been clearly laid down by Celsus, that in these cases the bone does
not bleed. The rule of practice, then, to operate in order to remove
the coagula of blood and matters which form between the skull and the
dura mater, was sanctioned by Sir Charles Bell and Sir Astley Cooper;
but they, like Mr. Abernethy, generally condemn interference when the
fluids are situated below the membrane. On this subject Mr. Guthrie
remarks:--“The operation of incising the dura mater, to admit of the
discharge of blood or matter from beneath, and even of puncturing
the brain, is much more commonly performed in France than in Great
Britain, where it is very rarely had recourse to, _and which may be
an error_,” etc. (p. 125.)
After thirty years’ further experience, this practice has been
tested by the recent statistics of Dr. Laurie, and the results, as
stated by him, are very discouraging. In the Hospital of Glasgow,
it was found in practice that there was no certain symptom whereby
it could be determined at what part of the head the blood had been
effused, nor, when discovered, could it, in general, be removed by
trephining the skull. The results, in short, were the following: “We
have thus thirty-nine cases in which extravasation existed as the
principal lesion, or as an important complication, in only one of which
extravasation existed as the principal lesion, or as an important
complication; in only one of which could an operation have saved the
patient; and of the seventeen cases operated upon, _not one_
recovered after, or was benefited by, the removal of the coagula.”
Such, then, are the results of modern experience, as far as they
are at present ascertained, in the use of the trephine for the
treatment of contusion, and undepressed fracture, complicated with
the effusion either of blood or of matter, from the days of Pott down
to the present time. The reader, however, should bear in remembrance
that the practice, of which the results have been shown to be so
unsatisfactory, is not that of Hippocrates, but of Celsus; for, in the
present instance, even Dr. Laurie repudiates the idea of operating
“for the purpose of relieving the evil consequences _which may
follow_ concussion of the brain,” and holds distinctly in this case
that one is not warranted in even entertaining the idea of operating,
unless--“first, when the puffy tumor indicates the spot which probably
has sustained the greatest amount of injury; second, such an inflamed
and suppurating condition of the injured soft parts as renders it more
than probable that the corresponding portion of the dura mater is in
a similarly diseased condition; third, inflammatory fever, preceded
or followed by rigors, and symptoms of compression.” From what has
been stated, then, it must appear evident that the recent statistics
furnish no test whatever of the results of the practice laid down by
Hippocrates, which was founded upon an entirely different principle,
namely, the preventive.
But, however anxious I may feel to prosecute further this comparison
of the results of ancient and of modern experience on this highly
interesting subject, my necessary limits compel me to bring this
discussion to a close. Before doing so, however, I shall briefly state
the inferences which I think may be drawn from a careful study of all
the principle authorities who have written on injuries of the head from
Hippocrates down to the present time:
1. All the serious injuries of the skull may be arranged conveniently
under the classes of contusions, simple fractures and fractures with
depressions.
2. Hippocrates recommended the operation of perforating the cranium, in
cases of simple fractures and contusions, whenever he apprehended that
these would be followed by serious consequences, such as inflammation,
extravasation of blood, and the effusion of matter.
3. Hippocrates operated in these cases during the first three days,
before any serious symptoms had come on, but Celsus rejected this
rule, and postponed the operation until after these effects had been
developed.
4. The objects which Hippocrates had in view by perforating the
skull, either entirely through or nearly so, would appear to have been
to slacken the tightness of the skull, and procure the evacuation of
extravasated blood lying within it.
5. The object for which Celsus opened the skull would appear to have
been solely to remove bodies which were creating irritation in the
brain.
6. All the ancient authorities looked upon contusions and simple
fractures as being very formidable injuries, which generally produce
congestion in the brain, with inflammation and effusion.
7. In modern times, at least within the last hundred years, the
trephine has never been applied in cases of contusion and simple
fracture, upon the principle of the operation acting as a preventive
of subsequent mischief, but only with the object of relieving effusion
when it was supposed to have taken place within the cranium, that is to
say, upon the plan recommended by Celsus.
8. The most contradictory accounts are given by modern authorities,
especially by the French surgeons of the eighteenth century, as to the
different results in cases of this description, when let alone, and
when treated upon the Celsian principle; and the recent statistics of
the operation are extremely unfavorable.
9. Hippocrates regarded fractures accompanied with depression and a
considerable separation of the bones as being generally less dangerous
than severe contusions and simple fractures, as in the former case
the brain is usually less hurt by the vibration of the shock which
inflicted the injury, and there is an outlet to any noxious matters
which may get congested in the brain.
10. Hippocrates, as a general rule, did not operate in cases of
depression, not even in cases of comminuted fracture, but in the latter
case left the pieces of bone to separate gradually by suppuration.
11. Celsus, on the other hand, approved of removing spiculæ at once,
of raising the depressed corner of a fractured bone, by sawing off the
superincumbent part, and even of perforating the adjoining bone, and,
in certain instances, of removing the whole of the depressed portion.
12. Pott laid it down as a general rule of practice, to operate with
the trephine in all cases of fracture accompanied with any considerable
degree of depression, and this formed the established practice in
this country, until the late Mr. Abernethy, about forty years ago,
introduced the rule of not interfering in such cases until urgent
symptoms had come on.
13. Of late years a further innovation has taken place in this rule
of practice in cases of depressed fracture, the operation being had
recourse to by Dr. Laurie and others, on the principle of preventing
the bad effects likely to result from the injury.
14. On whatever principle applied, the statistics of large hospitals
exhibit the results of the operation in a most unfavorable light,
insomuch that many of the most able and experienced surgeons of the
day hesitate whether, as a general rule, the operation ought not to be
abandoned altogether.
_Finally, a careful study of the whole literature of the subject,
from Hippocrates down to the present time, leads to the conclusion that
what constitutes the great difficulty in the treatment of injuries
of the head is, that the operation, to be successful, would require
to be performed early, and rather with a view of preventing serious
consequences, than of removing them after they have come on; and that
these can seldom be estimated so correctly as could be wished, since
they frequently bear no proportion to the apparent magnitude of the
mischief which the cranium has sustained._[767]
As the reader may find some difficulty in apprehending correctly the
nature of the instruments and other apparatus used by the ancients
in surgical operations, I have subjoined drawings of them, taken
principally from the works of Vidus Vidius and Andreas à Cruce, who
both lived at a time when these instruments must have been sufficiently
common in the cabinets of learned physicians, so that there is every
presumption that the figures which they give are sufficiently correct.
The manner in which they were used will readily be comprehended
from their shapes, assisted by the following lucid description of
the ancient process of trepanning the skull, given by Mr. Pott. “If
the piece of bone intended to be removed was larger than could be
comprehended within the modiolus (_trephine?_) then in use, and
which was a very defective instrument in many respects, the operation
was thus performed by means of terebræ. The piece intended to be taken
away was surrounded with perforations made at small distances from
each other, and then either the scalper excisorius or the scalper
lenticulatus was introduced, and, by means of repeated strokes with
a heavy mallet, was driven through all the interspaces between each
perforation. By these means the portion of bone so surrounded was
removed, and the dura mater was laid bare.”[768] That the modiolus of
Celsus was a small circular saw with a pivot, exactly like the modern
trephine, seems quite obvious from his own description of it; and that
the instrument called by our author terebra serrata (πρίων χαρακτὸς)
was identical with it, cannot admit of any doubt. See Foës, Œc. Hipp.
in voce πρίων.
Before concluding, I must also say a few words on one important point
connected with the constitutional treatment, which the modern reader
may at first sight be surprised to find no mention made of in this
treatise--I mean the use of venesection in the treatment of injuries of
the head. Now certainly it does not appear that Hippocrates regarded
bleeding as necessarily forming a portion of the system of treatment
in injuries of the bones of the head any more than in those of other
bones. But, although these were his views, it can be as little doubted,
by any one who is acquainted with his general views of practice, that
he bled whenever the abstraction of blood was indicated, either to
produce evacuation or revulsion. We know, for example, that in pains
of the back part of the head he opened the temporal vessels,[769]
and that in all inflammations and febrile diseases he abstracted
blood freely, nay, perhaps, _ad deliquium animi_.[770] And that
Hippocrates enforced the depletory system of treatment in injuries
of the head, when pain and inflammatory fever supervened, is quite
obvious, from its having been the system pursued in such cases by all
subsequent authorities, who looked up to him as their great guide in
practice. See PAULUS ÆGINETA, Book VI., 90, Syd. Soc. Edit.
I may mention further, as a proof that I am not straining a point
in the present instance, in order, as might be supposed, to bring
my author clear off in a case where he would appear to have been in
fault, that Ambrose Paré, who is a great advocate for depletion in
the treatment of fractures of the skull, is at great pains to show
that he has Hippocrates on his side in support of this practice.[771]
But while it is maintained that our author did not omit venesection
when properly indicated, I did not mean to say that he or any of the
ancient authorities carried the abstraction of the blood to the extent
practiced by Pott, or the members of the Royal Academy of Surgery in
France, nor as was done by the army and hospital surgeons of this
country during the late war.[772] Whether or not this was a defect
in ancient practice I shall not take it upon me to offer an opinion.
Suffice it to say, that there is undoubted evidence that in injuries
of the head the ancient surgeon, as is _naively_ recommended by
Avicenna, “bled his patient when he stood in need of being bled;”[773]
that is to say, according to special indications, and not in obedience
to any general rule.[774]
There is another point of practice in injuries of the head to which
it is proper that I should draw attention--I mean cold applications.
Now it is beyond a doubt that the application of cold in diseases of
the brain is pointedly condemned by Hippocrates, and that he used hot
applications instead;[775] and, moreover, that most of the ancient
authorities adhered to his rule on this point. At the same time it
would appear, that in extreme cases certain of them did not scruple to
apply ice to the shaved head.[776] I shall only remark further, that in
this case, as in diseases of the eyes, perhaps the safest rule is, to
be guided very much by the feelings and habits of the patient.
[The Plates referred to will be found at the end of the work.]
ON INJURIES OF THE HEAD
1. 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_, Τ; 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.[777]
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.[778] But
whoever has a prominence of the head both before and behind, in him
the sutures resemble the Greek letter _êta_ Η; 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.[779] But
whoever has no prominence on either part he has the sutures of the head
resembling the Greek letter χ; for the one line comes transverse to the
temple while the other passes along the middle of the head.[780] 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_.[781] 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.[782] 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
are wounded in the anterior part.[783] 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 _hædræ_ (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.[784]
4. The bone in the head is liable to be wounded 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.[785] 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 and 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 ease with certain fractures at a distance from the seat of
injury.[786]
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.[787] This is the third mode. There are many varieties
of depression, for it may comprehend a greater and a smaller extent
of bone, and may either be to a greater depth, or less so, and more
superficial.[788]
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]
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 be safe; and bones
which are broken by numerous and broader fractures are still less
dangerous and more easily extracted.[807] 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.[808]
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.[809]
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.[810] 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 before the
fourteenth day 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.[811] 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.[812]
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.[813]
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 fungous. 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.[814] 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,[815] and in doing so must frequently
take out the trepan and examine with a sound (specillum), and otherwise
along the tract of the instrument.[816] 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,[817] 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.
END OF VOL. I.
EXPLANATION OF THE PLATES TO VOL. I.
[Illustration: PLATE I.
FIG. 1. The Saw used by carpenters. (Taken from
_Chirurgia è Græco in Latinum conversa, Vido Vidio interprete
Lutetiæ Parisiorum_, p. 115.)
2. A small Saw. (_Ibid._)
3. The Modiolus, _or_ ancient Trephine. (_Ibid._)
4. The Terebra, _or_ Trepan, called Abaptiston.
(_Ibid._ p. 116.)
5. The Auger used by carpenters. (_Ibid._ p. 116.)
6. The Terebra, _or_ Trepan, which is turned round by a
thong bound tight about its middle. (_Ibid._ p. 117.)
7. The Auger, _or_ Trepan, which is turned round by a bow.
(_Ibid._ p. 118.)
8. A Terebra, _or_ Trepan, which is turned round by a
thong on a cross-beam. (_Ibid._ p. 119.)
9. A Terebra, _or_ Trepan, which has a ball in its upper
end, by which it is turned round. (_Ibid._ p. 120.)
10. A Terebra, _or_ Trepan, which is turned round by
a cross piece of wood, _or_ handle, on its upper end.
(_Ibid._ p. 120.)]
[Illustration: PLATE II.
FIG. 1. A Terebra, _or_ Trepan, turned round by a
handle in its middle. (_Ibid._ p. 122.) It resembles the
centre-bit of modern artisans.
1. A hole into which the iron head is fixed.
2. Upright part, three inches long.
3. Cross part, one inch long.
4. The part which is grasped in turning the instrument.
5. Cross part, an inch long.
6. Upright part.
7. A ball fixed to the top.
A. B. C. Different forms of the iron head fixed in the hole 1.
FIG. 2. Scalper rectus, _or_ straight Raspatory.
(_Ibid._ p. 123.)
3. Scalper in medio recurvatus, _or_ bent Raspatory.
(_Ibid._ p. 123.)
4, 5, 6. Ancient Modioli, as represented by Pott (_Injuries
of the Head_, p. 153).]
[Illustration: PLATE III.
FIGS. 1 and 2. A Scalper, _or_ Raspatory, with
which the moderns scrape the bone. (_Chirurgia è Græco,
&c._, p. 125.)
3. Scalper cavus _or_ scooped Raspatory. (_Ibid._ p.
126.)
4. A Lenticular. (_Ibid._ p. 127.)
5. A Malleolus, _or_ Mallet. (_Ibid._ p. 126.)
6. A Lever, by which modern surgeons protect the dura mater,
and raise a depressed bone. (_Ibid._ p. 128.)
7. The ancient Meningophylax. (_Ibid._ p. 128.)
8. Forfex excisoria, _or_ Cutting Scissors. (_Ibid._
p. 129.)
9. A Forceps, used for extracting bones. (_Ibid._ p. 130.)]
FOOTNOTES:
[1] It is necessary to inform my readers in this place, that, owing to
its bulk, it has been judged expedient by the Council of the Sydenham
Society to divide the work into two separate parts or volumes.
[2] This is the view which is taken regarding the origin of Grecian
medicine by Schulze, in his Historia Medicinæ. He is a most learned and
trustworthy authority on the history of medicine, but in the present
instance his judgment is biassed by the opinion which was generally
held in his age with respect to the origin of Grecian philosophy. At
that time it was customary to follow the later Platonists in tracing
the rise of philosophy to Egypt. Lord Monboddo, in his work on Ancient
Metaphysics, strongly espouses this opinion, which, in fact, was the
established belief of learned men down to a late period. Kant advocated
the views which are here adopted.
[3] See in particular the introductory chapters to Ritter’s History of
Ancient Philosophy; Thirlwall’s History of Greece, c. xii.; Grote’s
History of Greece, P. I., c. xvii. The opinion now generally held on
this subject may be explained in few words. The Homeric poems are
beyond all doubt of Grecian origin, for it cannot be shown that the
ancient Egyptians or Babylonians had anything resembling a regular
epos. Now, as Mr. Grote well observes, “from the poetry of Homer to
the history of Thucydides, and the philosophy of Plato and Aristotle,
was a prodigious step, but it was the native growth of the Hellenic
youth into the Hellenic man, and what is of still greater moment, it
was brought about without breaking the thread either of religious or
poetic tradition--without any coercive innovation or violent change in
the mental feelings. The transition of Grecian mind from its poetical
to its comparatively positive state was self-operated, and accomplished
by its own inherent and expansive force--aided indeed, but by no means
either impressed or provoked, from without.”--L. c.
[4] Plato, Menex.
[5] Celsus mentions Pythagoras, Empedocles, and Democritus, as the most
distinguished of the philosophers who cultivated medicine.--Præfat.
[6] “Hippocrates primus ab studio sapientiæ disciplinam hanc
separavit.”--Præfat.
[7] See the authorities quoted at PAULUS ÆGINETA, Vol. I.,
p. 73, Syd. Soc. edition; also in particular Xenophon’s Memorabilia,
iii., 13; and Pausanias, ii., 2. The most complete list which is
anywhere given of the ancient Asclepia, is that contained in Schulze’s
History of Medicine, i., 24. It is to be regretted, however, that the
references to Pausanias are made according to the pages of an old
edition, instead of books and chapters, so that one experiences some
difficulty in finding the passages referred to. The number of Asclepia
in Greece noticed by him is sixty-four. Plutarch states in positive
terms that all the Temples of Health were erected in high situations,
and where the air was wholesome.--(Quæst. Rom.) On the practice of
medicine in the Ancient Temples of Health, see further Sprengel, Hist.
de la Méd., e. v. Sprengel, however, does not acknowledge so candidly
as he ought to have done his obligations to his predecessor Schulze.
[8] Philostratus, Vita Apollonii, i., 9; Strabo, Geogr., xiv.
[9] Pausanias, vii., 21.
[10] This I have reason to know is the belief of the learned and
estimable author of the Isis Revelata.
[11] Aristides, Orat. in Æsculap., viii. It may be proper to state
that Sprengel, in referring to this passage (Hist. de la Méd., p. 160.
French edition), falls into the mistake of saying that these medicines
were prescribed to Aristides himself.
[12] Galen, de Administ, Anatom., ii.
[13] Censura Operum Hippocrat., p. 184.
[14] Hist. de la Méd., i., 5, p. 175, French edit. Schulze, in like
manner, depreciates the anatomical knowledge of the Asclepiadæ, and
holds that it had been overrated by Galen.--Hist. Med., i., 2, 5.
[15] Comment, in Libr. de Artie, iii., 28; de Decret. Hippocrat. et
Platon., viii., I.
[16] Polit., iii., 399; ed. Tauchnitz.
[17] Geograph., xiv., 2.
[18] De Sanitate tuenda, i.
[19] L. c.
[20] Galen, Opera, tom. iv., ed. Basil, 35.
[21] Aristotle, Polit., vii., 4. Notwithstanding the high compliment
which Aristotle here pays to the professional reputation of
Hippocrates, there can be no doubt that he does not always make proper
acknowledgment for the many obligations which he lies under to the Coan
sage. Galen states repeatedly that the greater part of Aristotle’s
physiology is derived from Hippocrates.
[22] See some ingenious observations on these mythical genealogies
in Grote’s History of Greece., vol. i., p. 593. He holds that they
are altogether unworthy of credit, or at least that there is no test
whereby one can separate the true from the false in them. Clinton,
indeed, in his Fasti Hellenici, attaches more importance to them; but
apparently Mr. Grote’s judgment on them is perfectly just. See further
vol. ii., p. 53, etc.
[23] Noctes Atticæ, xvii., 21.
[24] That Hippocrates drew the rudiments of his medical knowledge from
the reports of cases collected in the Asclepion of Cos, is attested by
good authorities. See Strabo, Geogr., xiv.; Pliny, H. N., xxix., 2.
[25] On the introduction of the gymnastic exercises into the practice
of medicine, see Schulze, Hist. Med., i., 2, 8. The author of the VI.
Epidem. condemns Herodicus for using exercises in the treatment of
acute diseases. Herodicus is frequently mentioned in the Dialogues of
Plato. See Protagoras, § 20; and de Repub., iii. Plato says, that being
in ill health, he wore out first himself and afterwards many others, by
combining gymnastics with medicine.
[26] Somnus alludes to this fiction, and quotes Andreas as an authority
for it. See also Pliny, H. N., xxix., 2. Tzetzes calls it the Temple of
Cos, and not of Cnidos, which was burned.
[27] See Plato, Protagoras.
[28] Galen, Comment. in Libr. de Nat. Human.
[29] Suidas in voce Hippocrates.
[30] It was a common practice in ancient times to kindle great fires
as _disinfectants_ or _deodorizers_. We have entered pretty
fully upon this subject in our Commentary on PAULUS ÆGINETA,
Vol. I., p. 274. There can be no doubt that it was the established
practice of the profession in the days of Hippocrates. The names of
Acron, Empedocles, and Hippocrates are particularly famous as having
successfully adopted the practice. See Aëtius, v., 94; Paulus Ægineta,
l. c.; Pliny, H. N., xxxvi., 69; and Plutarch, De Iside et Osiride.
[31] Hist., iii., 87.
[32] It deserves to be mentioned further, as adding probability to the
present narrative, that it was quite common in ancient times for the
Asclepiadæ to be publicly consulted by cities and States respecting the
general health of the inhabitants, and this both for the prevention and
cure of diseases. See Aristid. Opera, i., p. 81.
[33] Galen, in many parts of his works, alludes to the professional
services of Hippocrates during the great plague described by
Thucydides. He mentions decidedly that Thucydides gives only
those symptoms which would strike a common, that is to say, a
non-professional man; whereas Hippocrates describes the disease
accurately like a professional man, but gives few of those symptoms
which appeared most interesting to Thucydides.--De Difficult. Respir.,
ii., 7.
[34] Thucydides mentions that the mortality of the plague was greatly
aggravated by the influx of the people from the country into the city,
and the crowding of them in ill-ventilated huts. (ii., 52.) Mitford,
in describing the plague of Athens, remarks that the want of sewers
in ancient times must have contributed very much to the severity of
the disease. (Hist. of Greece, vol. ii., p. 195.) He refers (l. c.) to
Strabo (Geogr. v.) for proof that the Romans were the first people who
constructed sewers.
[35] See Xenophon, Cyropæd., i. and viii.
[36] Galen, Comment in libr. de Artic. iii.
[37] Xenophon, Anabasis, i. It has never been clearly determined
whether he was in the suite of Artaxerxes the king, or of his brother
Cyrus, before the battle of Cunaxa, in which the latter was killed,
and the former being severely wounded, was attended professionally by
Ctesias. Diodorus Siculus, indeed, says decidedly that he was taken
prisoner on the occasion. (Bibl. ii., 32.) But we are certain, from the
authentic narrative of Xenophon, that he was not taken prisoner in the
battle, nor is it likely that he was one of those who were kidnapped
afterwards, otherwise the historian would certainly not have omitted
the name of so distinguished a personage. Besides, had he been brought
to Babylon in this way, as a captive, Artaxerxes was not likely to
have intrusted his royal life to a person who had been so lately the
professional attendant on his rebel brother.
[38] See Thucyd., ii., 48.
[39] De Prisca Medicina.
[40] See in the next section, under xxiii. Though I have not admitted
the treatise here referred to into the list of genuine works, it will
be seen below that it possesses considerable evidence in its favor, and
that beyond doubt it is very ancient.
[41] Aphor., I., 1.
[42] See Galen, Opera, tom. v., p. 488; ed. Basil.
[43] This is clearly defined and stated by Aristotle, Phys., i. See
also Boethius in Præd., p. 113; ed. Basil.
[44] This is the more remarkable, as it does not appear to have been
the established creed of the greatest literary men and philosophers
of the age, who still adhered or professed to adhere to the popular
belief in the extraordinary interference of the gods with the works of
Nature and the affairs of mankind. This at least was remarkably the
case with Socrates, whose mind, like that of most men who make a great
impression on the religious feelings of their age, had evidently a deep
tinge of mysticism. See Xenoph. Memor., i., 1, 6–9; Ibid. iv., 7, 7;
also Grote’s History of Greece, vol. i., p. 499. The latter remarks,
“Physical and astronomical phenomena are classified by Socrates among
the divine class, interdicted to human study.” (Mem., i. 1, 13.) He
adds, in reference to Hippocrates, “On the other hand, Hippocrates,
the contemporary of Socrates, denied the discrepancy, and merged into
one the two classes of phenomena--the divine and the scientifically
determinable,--which the latter had put asunder. Hippocrates treated
all phenomena as at once both divine and scientifically determinable.”
(p. 499.) He then quotes the memorable passage in the treatise “On
Airs,” etc. It does not appear, however, that in ancient times the
charge of Atheism was ever brought against him. It has been urged
against him by modern fanatics, but scarcely deserves a serious
refutation. See Schulze (Hist. Med., i., 3, 2), and Ackerman (Hist.
Lit. Hippocr., pp. xii, xiii; ed. Kühn). By such persons, whoever does
not join in their anthropomorphical notions of a first cause is held up
for an Atheist.
[45] For the medicine of the ancient Jews, Egyptians, and Babylonians,
see the introductory chapters of Sprengel’s Hist. de la Méd. The
medicine of the Hindoos, as given in the “Susruta” of D’Hanvantare,
abounds in superstitious practices.
[46] Epidem., vi.
[47] Epidem., i.
[48] De Diæta in Morb. Acut., Prognost., 15. See the argument to the
Appendix to the former work.
[49] See Galen, Oper. tom. v., p. 106; ed. Basil.
[50] See De Morbis, pluries; de Prisca, Med., 22.
[51] De Superfœt. et pluries.
[52] De Ratione Victus in Acut. There is some doubt, however, whether
the σκαμμώνιον of Dioscorides be the _Convolvulus scammonia_. Some
rather take it for the _C. sagittifolius_.
[53] De Superfœt. et alibi.
[54] De Morb. Mulier.
[55] De Fract., Aphor. et alibi.
[56] Galen, Meth. Med., v., 3; Comment. in Libr. de Humor. See further
in illustration, Œconom. Hippocrat. under Παροχετεύειν and 'Αντίσπασις;
and Schulze, Hist. Med., i., 3, 4, 10.
[57] See Epidem., i, and iii.; Aphor., i., 16; and De Diæta Acutor.,
passim.
[58] See de Morbis, ii.; and Le Clerc, Hist. Med., 1, 3, 20.
[59] See the work “On the Articulations,” pluries.
[60] See in particular Venesect. adv. Erasistrat., Comment. in Lib. de
Offic. Medic.
[61] De Dyspn., ii., p. 181; ed. Basil. This brevity of style, Galen,
in another passage of the same work, pronounces to be characteristic
of all the old writings. In fact, when the materials of writing were
scarce and dear, it is not likely that authors would indulge in an
extravagant use of them.
[62] Coray, Traité de Hippocrat. des Airs, etc., Discours préliminaire,
pp. l., lvii.
[63] Dionysius Halicarnassensis de iis quæ Thucyd. propria sunt, et de
Platon. judicium.
[64] Opus supra laudatum, p. clxxiv.
[65] See the editions of Horace by Bentley and Tate, pluries.
[66] See in Bentley’s Horace. The poet himself in several of his
pieces, alludes to the separate publication of the various books, as
i., 97; vi., 1; ii., præfat.; et pluries.
[67] See Middleton’s Life of Cicero, pluries.
[68] See the editions by Ast, Bekker, and Stallbaum, and the ancient
authorities there referred to.
[69] See the preliminary dissertation prefixed to Buhle’s edition; also
Schneider’s edition of the Historia Animalium, Epimetrum iii.
[70] He mentions, in his commentary on the treatises entitled
“On Regimen in Acute Diseases,” that, from the marks of confused
arrangement about it, he was persuaded the author had left it in an
unfinished state, and that it had been published after his death. See
Opera, tom. v., p. 70; ed. Basil.
[71] See Galen, de Crisibus, i., 6.
[72] Galen, Gloss., tom. v., p. 705; ed. Basil. As frequent mention of
the commentators will occur in the course of this work, I will here
subjoin a complete list of them, with a few brief notices of them,
more especially of a chronological nature, derived principally from
the following sources: Ackerman, Bibliotheca Græca; Dietz, Præfatio
in Scholia Apollonii, etc.; Littré, Op. Hippocrat., tom. i., pp.
80–132; Daremberg, Cours sur l’Histoire et la Littérature des Sciences
Médicales.
Herophilus, the famous anatomist of Alexandria; flourished
about from 310–280 A.C.
Xenocrates of Cos, quoted by Erotian as an authority on the
Prognostics; nearly contemporary with Herophilus.
Philinus of Cos, contemporary with Herophilus, and probably a
disciple.
Bacchius, contemporary with Philinus.
Glaucias immediately after Bacchius; flourished probably
between 290–260 A.C.
Zeuxis the Empiric, immediately after Glaucias and before Zeno;
probably from 270–240 A.C. See Daremberg.
Heraclides Tarentinus, somewhat later than Bacchius, probably
between 260–240 A.C.
Zeno the Herophilean, the contemporary and rival of Heraclides;
probably the same as Zeno of Laodicea.
Apollonius Biblas, the contemporary and rival of Zeno.
Callimachus, according to Daremberg, an immediate disciple of
Herophilus.
Epiceleustus of Crete, of uncertain date.
Apollonius Ophis, of uncertain date.
Lysimachus of Cos, uncertain.
Euphorion, uncertain.
Heraclides the Erythrean, rather uncertain; but, according to
Daremberg, a contemporary with Heraclides Tarentinus. The same
as Heraclides the Herophilean. (Strabo, Geogr., xiv.)
Epicles, uncertain.
Eurycles, uncertain.
Philonides of Sicily, uncertain.
Ischomachus, uncertain.
Cydias, uncertain.
Cinesias, uncertain.
Demetrius, the Epicurean.
Diagoras, uncertain.
Nicander the Poet of Colophon, from 150–120 A.C.
Apollonius Citiensis; Daremberg places him between 80–52
A.C. See also Dietz and Littré.
Asclepiades of Bithynia, contemporary with Pompey the Great;
about 60–40 A.C.
Thessalus, the famous Methodist; about 50–70 P.C.
Erotian flourished in the reign of Nero, from 50–70
P.C. His Glossary still preserved.
Sabinus, of uncertain date, but probably not long anterior to
Galen, by whom he is frequently quoted. (Op., tom. v., p. 433.)
Metrodorus, disciple of Sabinus.
Rufus _or_ Ruffus Ephesius, contemporary with Sabinus.
Several of his works remain, but no portion of his Commentaries
on Hippocrates.
Marinus, the celebrated anatomist, about the beginning of the
second century P.C.
Quintus, the Empiric, probably about from 110–130 P.C.
Lycus, the Macedonian, the disciple of Quintus; from 120–140
P.C. See Daremberg.
Lycus, of Naples, date rather uncertain.
Artemidorus, a favorite of the Emperor Hadrian; often blamed
by Galen for his alterations of the text; about 120–140
P.C.
Dioscorides (_not_ the author of the Materia Medica), an
associate of Artemidorus.
Numesianus, somewhat later than Dioscorides.
Dionysius, about the time of the last.
Pelops, the disciple of Numesianus.
Satyrus, the disciple of Quintus.
Phecianus, the disciple of Quintus.
Julian the Alexandrian, the immediate predecessor of Galen, who
frequently animadverts on his writings.
GALEN, flourished between 150–190 P.C.;
wrote Commentaries, still in existence, on the following
works:--On the Nature of Man; on Regimen in Health; on Regimen
in Acute Diseases; on the Prognostics; on the First Book of the
Prorrhetics; on the Aphorisms; on the First, the Third, and the
Sixth Books of the Epidemics; on the Treatise on Fractures; on
the Articulations; on the Physicians’ Establishment or Surgery;
on the Humours; fragments of the Commentaries on Airs, Waters,
Places, and on the Aliment. Besides these, he wrote several
other Commentaries, which are lost.
Domnus, of uncertain date, after Galen.
Attalion, like the last, cited in the Commentary attributed to
Oribasius.
Philagrius, of uncertain date, quoted by Theophilus.
Gesius, of uncertain date.
Asclepius, of uncertain date, quoted by Theophilus. (Dietz,
tom. ii., p. 458.)
Stephanus, the Athenian, supposed by Dietz to have lived in the
reign of Heraclius, that is to say, in the earlier part of the
seventh century. According to Dietz, not the same as Stephanus
Alexandrinus.
Palladius, probably about the seventh century; his Commentary
on the book “On Fractures,” published by Foës, and a
considerable portion of his Commentary “On the Sixth Epidemic,”
by Dietz.
Joannes Alexandrinus, probably near the time of Palladius; part
of his Commentary “On the Nature of the Young Man,” published
by Dietz.
Theophilus, or Philotheus, surnamed Protospatharius, probably
flourished in the seventh century P.C. See the
Annotations of Dr. Greenhill, in his excellent edition of the
work “De Corporis Humani Fabrica;” Oxford, 1842. Several of his
Commentaries on the Aphorisms, published by Dietz.
Meletius, of uncertain date; part of his Commentaries on the
Aphorisms, published by Dietz. See also Anec. Gr., ed. Cramer.
Damascius, of uncertain date; a few of his Commentaries on the
Aphorisms, published by Dietz.
[73] Œuvres d’Hippocrat., tom. i., p. 171.
[74] See Schulze, Hist. Med., i., 3, 1.
[75] It will be proper to give this Class:--
1. De Aëre, Aquis, et Locis.
2. De Natura Hominis.
3. De Locis in Homine.
4. De Humoribus.
5. De Alimento.
6. De Morbis popularibus.
7. Prognosticon.
8. Prædictionum, ii.
9. De Victu Acutorum.
10. De Fracturis.
11. De Articulis.
12. Mochlicus.
13. De Vulneribus Capitis.
14. Officina Medici.
15. Aphorismi.
[76] Censura Librorum Hippocrateorum, Vratislaviæ, 1772.
[77] De Elementis, i., 9.
[78] Tom. v., p. 442; ed. Basil.
[79] Galen, who is a most unexceptionable judge in such a case, says
that the language of Hippocrates inclines to the Attic, and that some
had held it to be Old Attic. (Tom. v., p. 525; ed. Basil.) Dionysius
of Halicarnassus, another admirable critic, says that Herodotus is the
most excellent standard of the Ionic (and so, by the way, Photius also
says, under the head of _Ctesias_) and Thucydides of the Attic.
(De Platon. Judicium.) Now, since we have already made it appear that
there is a most striking similarity between the language of Hippocrates
and Thucydides, the judgment of Dionysius is evidently in accordance
with that of Galen on this point. Indeed, as briefly stated in the
text, the Attic was nothing more than a new development of the Ionic,
and scarcely more different from it than the English language in the
age of Pope is from the same in the age of Milton. It is to be borne
in mind that the name Ionian was originally applied to the Thracians
and the inhabitants of Attica, who were evidently closely allied to
one another in consanguinity. It was in Thrace that learning and
civilization first sprang up under the auspices of Thamyris, Orpheus,
and Musæus, by whom the elegant arts were transplanted to Athens.
(See Hesychius, in voce Iones; Eustathius, ad Iliad., ii.; Diogenes
Laertius, _Prœfat_.; also Hermes Philologus, p. 23, by the author
of this disquisition, whose mind now reverts with great delight, _ad
studia quæ adolescentiam alebant_.) The inhabitants of Asiatic Ionia
and the adjoining islands were colonists from Attica. (Thucyd., i.,
12; Herodotus, viii., 44; Heraclides, de Polit.) From what has been
stated it will readily be understood that the only standard of polite
Greek was the Ionic, with its offspring the Attic. The Æolic and Doric
dialects, although used in certain scientific and popular compositions,
such as Bucolics and certain philosophical treatises, were never looked
upon as being fashionable and learned dialects.
[80] De Artic., i.
[81] See his Historia Literaria Hippocratis, in the Bibliotheca Græca
of Albertus Fabricius, or in vol. i. of Kühn’s edition of Hippocrates.
[82] Galen, tom. v., p. 17; ed. Basil.
[83] Apologie, etc.
[84] Hippocratis nomine quæ circumferuntur scripta ad temporis rationes
disposuit Christianus Petersen, p. prior. Hamburgi, 1839.
[85] Prædict., i.; Coacæ Prænot.; de Loc. in Hom.
[86] De Carne.; de Part. Sept.; de Part. Oct.; de Superf.; de Dent.
[87] De Flat.
[88] De Morb. Popul., i., iii.; de Morb., i.; de Affect.; de Morbo
Sacro; de Insan.; de Veratr. Usu; de Victu Acut.; de Victu Sal.; Præn.;
Prædict., ii.; Aphor.; de Aëre, Locis, et Aq.; de Insom.; de Hæmorrh.;
de Fistul.
[89] De Nat. Puer.
[90] De Prisca Med.
[91] De Nat. Hom.; de Humor.; de Nat. Oss.; de Corde; de Corp. Sect.;
de Gland.; de Visu; de Alim.; de Usu Liquid.; de Affect. Intern.; de
Morb. Popul., ii., iv., etc.; de Morb., ii., iii.; de Morb. Mulier.; de
Nat. Mulieb.; de his quæ ad Virg. Spect.; de Steril.; de Vulner.; de
Judic.; de Dieb. Judic.
[92] De Morb., iv.; de Genitura; de Remed. Purgant.
[93] De Victu Sanor. libri tres.
[94] Tom. ii., pp. 32, 33.
[95] Œuvres d’Hippocrate, tom. i., p. 263.
[96] See Stephanus, Comment. in Prognost. Hippocrat., tom. ii., p. 61,
ed. Dietz.; and Galen, tom. v., p. 328, ed. Basil.
[97] The well known story regarding the concealment of Aristotle’s
library by his heir, Neleus of Scepsis, and its restoration by
Apellicon, is faithfully related by Strabo, Geograph., ix. In this
passage Strabo states, that before the restoration of the library by
Apellicon, there were but few of Aristotle’s works in the hands of the
peripatetic philosophers, and these principally his exoteric works. But
that the treatise “On the History of Animals” was an exoteric work, can
admit of no question. This is confidently maintained by the learned
Schneider in the prolegomena to his edition of this work. Indeed, as
he suggests, there is no good reason for doubting that the treatise
“On the History of Animals” had been published by Aristotle in his
lifetime. (Epimetrum, ii.) See also Buhle’s dissertation prefixed to
his edition of Aristotle’s works. I need scarcely add that, it being
thus shown that all the most learned authorities on the literature of
Aristotle’s works are agreed that the History of Animals, in which is
contained this disputed fragment on the veins, was published before the
time when the Hippocratic Collection is supposed to have been made, M.
Littré’s conclusions on this head must fall to the ground.
[98] The death of Aristotle is referred to A.C. 321. Now
this is just about the date of the foundation of the Royal Library at
Alexandria, and very near the age when Herophilus flourished. These (M.
Littré’s) positions clearly made out, it would follow that the dates of
the treatises in the Collection come down very near to the foundation
of the Alexandrian Library.
[99] See Hengstenberg’s Commentary on the Psalms, pluries.
[100] Although this piece be admitted into the first class, it also
merits a place here.
[101] Prænotiones or Prognostica; Aphorismi; Epidemiorum, i., iii.; de
Diæta Acutorum; de Aëre, Aquis, et Locis; de Capitis Vulneribus.
[102] De Prisca Medicina; de Articulis; de Fracturis; Mochlicus;
Jusjurandum; Lex; de Ulceribus; de Fistulis; de Hæmorrhoidibus; de
Officina Medici; de Morbo Sacro.
[103] Prorrhetica, i.; Coacæ Prænotiones.
[104] De Natura Hominis; de Salubri Victus Ratione; de Natura Muliebri;
de Morbis, ii., iii.; de Superfœtatione.
[105] De Flatibus; de Locis in Homine; de Arte; de Diæta; de Insomniis;
de Affectionibus; de Internis Affectionibus; de Morbis, i.; de
Septimestri Partu; de Octimestri Partu; Epidemiorum, ii., iv., vii.; de
Humoribus; de Usu Liquidorum.
[106] Epistolæ; Thessali Legati Oratio; Oratio ad Aram; Atheniensium
Senatus-Consultum.
[107] De Genitura; de Natura Pueri; de Morbis, iv.; de Mulierum Morbis;
de Virginum Morbis; de Sterilibus.
[108] Epidemiorum, v., vii.; de Corde; de Alimento; de Carnibus; de
Septimanis; de Natura Ossium; de Glandulis; de Medico; de Decenti
habitu; Præceptiones; de Anatomia; de Dentitione; de Exsectione Fœtus;
de Visu; de Crisibus; de Diebus Criticis; de Medicamentis Purgativis.
[109] Hippocrat. Coi Comment. etc., Theod. Zuingeri studio. Basil, 1579.
[110] See his additions to Ackerman’s Dissertation, in his edition of
the Works of Hippocrates.
[111] § 122, tom. i., p. 172 (ed. Bekker), where see the note of
Heindorf.
[112] Galeni Opera, tom. v., pp. 2, 16; ed. Basil.
[113] Œuvres Complètes, etc., tom. i., p. 320.
[114] The argument turns principally on the meaning of the expression,
τι πότε λέγει Ἱπποκράτης τε καὶ ὁ ἀληθὴ λόγος, which M. Littré contends
signifies, “ce qu’Hippocrate et la raison _pourraient dire_.”
Now I must say that, to me, the words of Plato here quoted do not
warrant the interpretation which M. Littré puts upon them; and, not
satisfied with my own judgment on this point, which happens in the
present instance to be an important one, I applied to one of the best
authorities in Britain on the minutiæ of the Greek language for his
opinion, and was happy to find that it entirely corresponded with my
own. Having alluded in the text to the prolixity of the discussion
which M. Littré enters into on this occasion, I trust that eminent
scholar will not be offended (provided these pages ever meet his eyes)
if I introduce here an anecdote of the celebrated Kuster. Having been
shown a work in which the quantity of argumentation and reflection
greatly over-balanced the amount of facts and references, he laid it
aside with the remark, “I find nothing here but reasoning: _non sic
itur ad astra_.”
[115] Galeni Opera, tom. v., p. 119; ed. Basil.
[116] Comment. vii.; et sect. vii., 53 et seq.
[117] See under _Hippocrates_ in Smith’s Greek and Roman
Biographical and Mythological Dictionary.
[118] “In all paroxysms, or sharp fits of intermitting diseases, we
must take away meat, for then to give it is hurtful.”
[119] “The belly is naturally hottest in winter and the spring,
and most addicted to rest. Consequently in these seasons a greater
proportion of food is to be allowed, because the inward heat is
stronger, which is the reason that a more plentiful food is necessary.
This difference may be seen in such as are old, and in such as are
lusty and well-grown bodies.”
[120] “Those things that are or have been justly determined by nature,
ought not to be moved or altered, either by purging or other irritating
medicines; but should be left alone.”
[121] “Things evacuated and purged are not to be estimated by the
multitude and quantity, but by their fitness to be avoided and sent
forth; and must be such as are not too troublesome to the patient to
bear. Though, where it is necessary, we must proceed in evacuating,
even to swooning and fainting, if the patient can bear it.”
[122] “Those who are grieved in any part of the body, and are scarce
sensible of their grief, have a distempered mind.”
[123] “When the upper parts of the throat or gullet are sore, or a
breaking out of small tumours does arise in the body, we ought to look
upon the excrements; for if they are choleric, the body is also sick;
but if they are like the excrements of sound persons, the body may be
nourished without danger.”
[124] “When that which ought to be evacuated is discharged by
spontaneous vomiting and diarrhœa, it is useful and easily endured; but
when otherwise, the contrary. _This is equally true with regard to
every vessel_,” etc.
[125] “They in whom the greatest vigor of the disease is immediately
perceived, are to be immediately sparingly supplied with food; but from
those in whom it occurs later, the food must at that time, or a little
earlier, be abstracted. Previously, however, we must nourish more
freely, that the sick may be supported.”
[126] “Whilst the crisis is forming, and when it is complete, nothing
ought to be moved or to be introduced, whether by purgatives or other
irritants; but all should be left at rest.”
[127] “They who are accustomed to daily labor, although even weak or
old, endure it more easily than the robust or young, who are even
accustomed to it.”
[128] “In regard to the seasons, if the winter has been dry and cold,
and the spring moist and warm, in summer acute fevers, ophthalmias, and
dysenteries must necessarily occur, chiefly, however, among females and
men of pituitous temperament.”
[129] Tom. v., p. 399; ed, Basil.
[130] “The state of the air being, upon the whole, dry, with a south
wind, which was just contrary to what happened the year before, when
the north chiefly prevailed; there were but few inflammatory fevers,
and these were of a mild disposition, very few being attended with
hemorrhages, and much fewer, if any, with death.” (p. 4.)
“They affected children, young persons, and those who were arrived at
years of maturity, and especially those who used much exercise, yet but
few women.” (Ibid.)
“Before the summer, and even during that season, nay, in winter
likewise, there were many who had been disposed to a phthisis who were
now afflicted with that disease,” etc. (Ibid.)
“The extremities were generally very cold, there was seldom any heat in
them.” (p 3.)
[131] Præfat. Gloss.
[132] Comment. in Libr. de Fract.
[133] In Lib. Prognos. Comment.
[134] Tom. v., p. 89; ed. Basil.
[135] Comment. in Lib. de Fract.
[136] Deipnos, ii., 7.
[137] De Propr. Lib., in III. Epid., Comm. ii., Præf.
[138] Bibl. Med., p. 1, 29, 59.
[139] The inhabitants of Asiatic Ionia, and the islands adjoining, were
all colonists from Attica. (See in particular Thucyd., i., 12; and also
Herodot. viii., 44; and Heraclides, de Politiis.) Dr. Coray supposes
that Hippocrates represents himself as being a European, in consequence
of his having composed this treatise in Europe, at a distance from his
native country. But there is no necessity for this supposition, as
Hippocrates, being of Grecian descent, would naturally enough consider
himself a European, since the great body of the Greeks were Europeans.
Coray mentions a striking instance of Haller’s incapacity to form a
correct judgment on the works of Hippocrates, from want of a proper
acquaintance with the Greek language.--Discours Préliminaire, etc., p.
lvi.
[140] De Placit. Hippocr., et Platon. ix.; de Diff. Resp., iii., 7.
[141] Ap. Foës., p. 197.
[142] Galeni Opera, tom. v., p. 652; ed. Basil.
[143] Opera, tom. v., p, 578; ed. Basil.
[144] Ibid., p. 170.
[145] In Prædict. i., Comm. i., 4.
[146] V. Galen, in Exeges. in vocibus ἐκλούσθω, σφάκερος, etc.
[147] Præfat. Gloss. Hippocrat.
[148] Gynæc., tom. i., P. I., p. 13.
[149] In vita Hippocrat.
[150] Ad Nepotian. de vita Cleric., Ep. ii., p. 13, tom. i.; ed. Paris,
1643.
[151] Orat. Funebr., in Cæsarium Fratrem.
[152] Sub voce Hippocrates.
[153] Epist. ad C. Jal. Callistum.
[154] Thesmophor., l. 240.
[155] De Legg. iv., l. vi., p. 134; ed. Tauchnitz.
[156] Tom. ii., p. xlviii.; Add. et Corrig.
[157] Tom. v., p. 526; ed. Basil, etc. Elsewhere he quotes it as being
undoubtedly genuine.--De Placit. Hippoc. etc., ix., 1.
[158] Hist. Med., p. 283.
[159] See Polybius, as quoted by Littré, l., c.; also section iii. of
the Preliminary Discourse.
[160] Saturnal., vii., 6.
[161] Hist. Animal., iii., 3.
[162] In Boerhaav., Meth. Stud. Med.
[163] De Placit. Hippocrat. et Plat., vi., 3; et Opera, tom. v., p. 22;
ed. Basil.
[164] De Nat. Facult., tom. i., p. 87.
[165] Opera, tom. v., p. 329; ed. Basil.
[166] See English translation of PAULUS ÆGINETA, Book I., p.
549.
[167] See Galen, tom. v., p. 2.
[168] See further, under No. 1.
[169] Opera, tom. v., pp. 17, 29.
[170] See PAULUS ÆGINETA, I., 50.
[171] I., 3.
[172] Sect. ii., near the beginning.
[173] Comment. in III. Epidem.
[174] Ad Hippocrat. de Aëre, Aquis, Locis, § 65.
[175] De Vulneribus superciliis allatis. Lips., 1741.
[176] Lehre von den Augen-krankheiten. Wien, 1813.
[177] In VI. Aphor., 3, Comm. vi.; Meth. Med., iv., 6.
[178] Hist. Med., i., 3, 4, 60. His language is particularly strong:
“Maximè genuinus ab omnibus judicatur.”
[179] In his Commentary on this work.
[180] Book iv., 44. See the authorities quoted in the Commentary on
this chapter in the English edition. Schulze properly remarks, that
the composition which he recommends as an application to certain sores
resembles the Ægyptiacum of modern times.--Hist. Med., i., 3, 4, 63.
[181] Comment in Lib. de Nat. Human.
[182] They are as follows: “Continuari cum libello de hæmorrhoidis
manifeste spurio, ideoque ipsum esse spurium, Galenus jam notat in
Gloss., s. v. πήρινα et στρυβλήν.” Now, as stated above, Galen does not
say a word against the authenticity of these works.
[183] Comment i., in Hipp. Prognost. The quotation prefixed to this
work in the editions of Vander-linden and Frobenius, in which Galen is
stated to have held this work not to be genuine, is admitted by Littré
to be of no authority.
[184] Morb. Diuturn., i., 4.
[185] See Menage in Diogen. Laert., p. 241.
[186] See § 66, tom. vii., p. 359: ed. Bekker.
[187] See all these authorities as quoted by Ackerman.
[188] Hist. de la Méd., i., iii., 4.
[189] It may appear a singular idea that the earth is supported on air,
and yet it was very generally held by the learned men of antiquity. The
poet Lucan thus alludes to this doctrine:
“Dum terra fretum terramque levabit
Aer.” Pharsal., i., 89.
And in like manner Ovid:
“Nec circumfuso pendebat in aere tellus
Ponderibus librata suis.” Met., I., 11.
Bentley remarks, in his note on the passage in Lucan, “Omnis poetarum
chorus hoc prædicat ut et philosophorum veterum.”
[190] Morb. Chron., i.
[191] Corp. Human. Appell., ii., 1.
[192] See under θήριον and κρημνόι.
[193] They refer apparently to Deipnos, ii., 7, where Athenæus quotes
a treatise of Hippocrates περὶ τόπων, but he evidently means by it the
work “de Aëre, Aquis, Locis.” It is to be borne in mind that Athenæus
often makes his references in a loose manner.
[194] De Facult. Natur., ii.
[195] Censura Libr. Hippocrat., p. 115.
[196] Comment. in Epidem., ii., 3. See also Le Clerc, Hist. de la
Méd., iii., 17; and Sprengel, Hist. de la Méd., tom. i., p. 325, etc.
A passage, which we shall see below, in the Prognostics (§ 15) puts it
beyond a doubt that venesection was part of the routine of practice
pursued by Hippocrates in cases of pneumonia. See also (and this
passage is very decisive) de Diæta in Morb. Acut., § 5; and Galen’s
Commentary, pluries.