The genuine works of Hippocrates, Vol. 1 · Hippocrates
THE ARGUMENT.
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.
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.]
Ideas discussed in this chapter
Text from Project Gutenberg, public domain in the United States.