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

by 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. 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]

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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.