The genuine works of Hippocrates, Vol. 1 · Hippocrates
THE ARGUMENT.
This treatise opens with a description of the bones of the head, which, although in most respects pretty accurate, is remarkable for containing an account of particular configurations of the cranium, and of certain varieties in the arrangement of the sutures, which it has puzzled modern authorities in anatomy to explain, otherwise than upon the supposition that the writer must have been but imperfectly acquainted with the subject. But as the work otherwise bears evidence that our author must have examined the bones of the head very carefully, and moreover, as in all his works he displays a wonderfully minute acquaintance with osteology, (to say nothing of the historical tradition, mentioned by Pausanias, that he was possessed of a skeleton, which at his death he bequeathed to the Temple of Apollo, at Delphi,) it seems incredible that he should have committed most glaring blunders in describing the prominent features of a part to which it is clear that he had paid very great attention. Moreover, the reputation of Hippocrates for accuracy stood so high, that an eminent authority does not hesitate to declare of him, that he was a man who knew not how to deceive or be deceived.[744] An easy way of getting rid of the difficulty would no doubt be, to adopt the conjecture advanced by Scaliger,[745] and in part approved of by Riolanus,[746] that the treatise had suffered much in early times, from the interpolations of ignorant transcribers; or to hold, with M. Malgaigne, that the whole work is to be condemned as spurious. But it would be a dangerous practice in ancient criticism, to reject as spurious a work which has such unexceptionable evidence in its favor, although it may contain matter which appears to us derogatory to the reputation of its author, and it will be admitted, by any competent judge who examines the arguments by Scaliger, that the proofs which he brings forward of great interpolations in this treatise, are generally of a very fanciful nature.
On a point so obscure, and which has puzzled so many eminent scholars, it is to be feared that I shall not be able to throw much additional light, but as, consistently with my general plan, I cannot well avoid stating some opinion on the question I shall endeavor to elucidate it in so far by giving in the first place a brief sketch of the information supplied by all the other ancient authorities who have touched upon this subject. I shall begin, then, with Aristotle, the contemporary of our author, who, in his work “On the History of Animals,” gives the following very inaccurate description of the sutures of the human skull: “The female cranium has one circular suture, but men generally three, which unite in one point. But a male skull has been seen not having a suture.”[747] Celsus describes the sutures in the following terms: “Ex ceteris, quo suturæ pauciores sunt, eo capitis valetudo commodior est. Neque enim certus eorum numerus est, sicut ne locus quidem. Ferè tamen duæ, super aures, tempora a superiori parte discernunt; tertia ad aures, occipitium a summo capite deducit; quarta, ab eodem vertice per medium caput ad frontem procedit; eaque modo sub imo capillo desinit, modo frontem ipsam secans inter supercilia finitur.” (viii., 1.) “Nam neque utique certa sedes, supra posui, suturarum est.” (viii., 4.) Pliny gives the following description of the head, which it is impossible not to recognize as having been borrowed from our author: “Vertices bini hominum tantum aliquibus.
Capitis ossa plana, tenuia, sine medullis, serratis pectinatim structa compagibus.”[748] Of Ruffus Ephesius I may just mention, that his descriptions of the human body are in general remarkable for their correctness, which is not to be wondered at, as he would appear to have followed, in general, Erasistratus and the other authorities belonging to the great Alexandrian period in anatomy; and that he has described very accurately all the sutures of the human cranium, but says not a word of the different configurations of the head, as here given by our author.[749] We now come to Galen, who gives a very lengthy description of the various forms of the head, in nearly the same terms as our author, and after alluding to the uses of the sutures, the principal of which he holds to be to permit transpiration from the brain, he proceeds thus to describe the distribution of the sutures: “That there is one which runs straight along the middle of the head, (the sagittal?) and two transverse, (the coronal and lambdoid?) has been stated previously, and need not require many words in this place.
For, the head being like an oblong sphere, one was justly made to extend straight through its middle from behind forwards, and two transverse sutures meet it, and the form of the three sutures is like the letter H. For the whole head being more elongated in this case than usual, and, as it were, compressed towards the ears, it was equitable that the number of the sutures should be unequal as to length and breadth, otherwise Nature would undeservedly have been named just, by Hippocrates, in thus giving equal gifts to the unequal. But it is not the case; for being most just, she formed the strongest suture which extends along the length of the head single, being thus proportionate to the width of the parts on both sides of it; namely, on the right and on the left; but she formed the transverse double in number, the one behind, as formerly said, called the lambdoid, and the other before, called the coronal, so that the bone of the head between these two sutures might be equal to those in the middle, on each side (the parietal bones?). The sutures of the head, in that configuration which is acuminated,[750] furnish a very great example of the justness of Nature.
For there are three principal figures of the head: the one entirely opposed to the natural configuration already described, when the head loses both its protuberances, that behind and the other before, and is equal on all hands, and like a true sphere; and two others, the one form having no protuberance in front, and the other none in the occiput. The sutures of the spherical head are like the letter χ, two only in number, and intersecting one another; the one extending transverse from the one ear to the other, and the other extending straight through the middle of the vertex to the middle of the forehead. For, as when one part of the head is excessive, being longer than the other, it was just that the longer form should have more sutures, so, when both are alike, Nature bestowed an equal number on both.
But in the head which wants the protuberance at the occiput, the straight and the coronal sutures remain, but the lambdoid is wanting (it being near to the protuberance that is wanting), so that the figure of the two resembles the letter T; as also when the protuberance of the head in front is wanting, the coronal at the same time is wanting, but there remains the one running lengthways and joining the lambdoid, and this form of construction is made to resemble the letter T. A fourth species of acuminated (sugar-loaf) head might be imagined, but which does not occur, with the head more prominent at the two ears than in front and behind.” He goes on to state the reasons why there is no such construction of the head as this, and concludes as follows: “Wherefore Hippocrates described four configurations, and the sutures of each, in the manner we have now said that they exist, being justly distributed to each configuration by Nature as to position and number.”[751] The description of the bones and sutures of the head, given in the Latin work “De Ossibus,” generally attributed to Galen, is to the same effect. The same number of distinct configurations of the head, and the same characters as regards the sutures, is also given by Avicenna, who professedly copies from Galen. (I., i., 5, 3.)
When examined together, these descriptions certainly must be admitted to have the appearance of being all derived from one original, namely, from our author, in this place; and taken literally, there can be no doubt that their meaning amounts to this: that the number of the sutures varies with the form of the head; that when there are protuberances both before and behind, the head in its upper part has two transverse sutures, namely, the coronal and the lambdoid, and one longitudinal, namely, the sagittal; that if the anterior protuberance be wanting, the coronal is wanting, and, if the posterior, the lambdoid. Now I need scarcely remark, that modern anatomists do not recognize such varieties in the configuration of the head nor in the numbers of the sutures, and that it is very rare indeed for either the coronal or the lambdoid suture to be found wanting. To all appearance, then, Galen was mistaken, and it only appears remarkable that, with all his knowledge of anatomy, theoretical and practical, and considering the opportunities which he must have possessed of examining human skeletons in Alexandria, he should have failed to observe and describe the bones of the cranium for himself. Before stating my own conjectures on this question, it may be 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.
Ideas discussed in this chapter
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