Part 11

Among the most remarkable features of the Hippocratic Collection is the feeling of contact with the patient which most of its works convey. This is naturally a special characteristic of the surgical works. One treatise, which bears the title On wounds of the head, has always drawn attention as bespeaking especial ingenuity and experience. The description of trephining is of peculiar interest, because the practice was known in prehistoric times and is still employed by savage and semi-civilized peoples. The process recommended for cases of fracture of the skull and injury to the underlying structures resembles, in many details, the modern surgical procedure.

‘When it is necessary to trephine a patient, make up your mind and judge as follows. If you have had charge of the case from the first, do not trephine the bone down to the membrane at once, for it is not desirable that the membrane be long exposed, lest it end by becoming rotten and fungous. There is also another danger, to wit that you wound the membrane with the saw during the operation, if you try to remove the bone by trephining immediately down to the membrane. Therefore, when the bone is almost sawn through and is already loose, cease trephining and allow the bone to come away of itself. While trephining, often remove the instrument and dip it in cold water. If you do not do this, the trephine, becoming heated by the circular motion and heating and drying the bone, may burn it and cause an unduly large piece of the bone round the sawing to come away.’

a Simplest form of trephine. It has central pin and serrated edge. The point is held against the skull and the staff twirled between the hands. (Cf. Fig. 112.) It could also be rotated by a crosspiece and thong, as in Fig. 22. b Case of scalpels from a bas-relief in the temple of Aesculapius on the Acropolis at Athens. c Trephining instrument of type still in use. The carpenter’s ‘center bit’ was known in antiquity, and was probably adapted to the trephine. a and c represent sixteenth-century instruments of ancient type. No ancient trephines of Greek origin are known, though a specimen has come down to us from Mesopotamia, see Fig. 3.

So much for a normal case which comes to the physician’s hands directly after the accident. But in less fortunate cases he is not called in so early, and the wound suppurates before he can bring his Art to bear upon it. In such a case he is advised:

‘Saw the bone immediately to the membrane with a serrated trephine (Fig. 9, a and c), frequently removing the trephine and testing with the probe all round along the track, for the bone is sawn through much more quickly if it is already suppurating and penetrated by the pus. The bone, however, often happens to be thin in places. Therefore be on your guard not to apply the trephine at random, but fix it in the bone where it appears thickest, frequently making an examination and trying to raise the bone by moving it. And after removing it, continue such treatment as may appear advantageous to the wound, according to circumstances.’

Among the works of the Hippocratic Collection is a lecture note-book known by the title Concerning the things in the Surgery. It is written in very abbreviated style and consists of mere headings. Nevertheless, our attention is arrested by its startling modernness, when we read such a category as this:

‘Operative requisites in the surgery: the patient; the operator; assistants; instruments; the light, where and how placed; the patient’s person and apparatus. The operator, whether seated or standing, should be placed conveniently to the part being operated upon and to the light. Each of the two kinds of light, ordinary or artificial, may be used in two ways, direct or oblique.’

Or again, such details as:

‘The nails [of the operator] neither to exceed nor come short of the finger-tips. Practise using the finger-ends. Practise all operations with each hand and with both together, your object being to attain ability, speed, painlessness, elegance and readiness. Let those who look after the patient present the part for operation as you want it, and hold fast the rest of the body so as to be all steady, keeping silence and obeying their superior.’

Are we not here reminded of an up-to-date operator and operating theater?

In the Hippocratic Collection the physician attends cases of every type, and does not refuse to do his best for a case because the use of an instrument is demanded. He is thus no ‘specialist’. But the mass of his practice lay with cases to which instrumental treatment was inapplicable. In cases in which surgical intervention was not justified the Hippocratic physician adopted for the most part what is called an ‘expectant’ line of treatment. Realizing that, in general, the tendency of the body is to recover, he contented himself with ‘waiting on Nature’. This does not by any means imply that he was helpless, for much could be done by nursing, regimen and diet to aid the patient in that conflict which he alone must fight out. For the conduct of that great battle wise and useful directions are recorded. But believing in the healing power of Nature--the famous phrase is used in the Hippocratic writings--the physician was none too eager to administer drugs. In the state of knowledge of the day this reluctance was well-judged. Nevertheless the Hippocratic drugs, though neither numerous nor complex, were some of them very efficient, and their judicious if reluctant use at the right juncture saved many a life.

The Aphorisms is the most famous book with which the name of Hippocrates is associated, and is as likely as any of the Collection to be by Hippocrates himself. It consists of a series of very brief generalizations. Many of these have been confirmed by the clinical experience of later ages. Some have passed into medical commonplaces, others have become popular proverbs. The style of the work suggests an aged physician reflecting on the experience of a lifetime. Among modern medical writings its closest analogue is perhaps the Commentaries of the great English physician, William Heberden the elder (1710-1801), which was commenced by him after the age of seventy, occupied the last twenty years of his life, contained a summary of the whole of his vast experience, and was published by his son after his death. If the Aphorisms is similarly a work of the old age of Hippocrates it may be dated about 380 B.C. A few extracts give a good idea of the nature of the book.

‘Life is short and Art is long; the Crisis is fleeting, Experiment risky, Decision difficult. Not only must the physician be ready to do his duty, but the patient, the attendants, the external circumstances must conduce to the cure.’

‘Old persons bear fasting most readily, next adults, and young people yet less; least of all children, and of these least again those who are particularly lively.’

‘If in any illness sleep does harm, it is a symptom of deadly import.’

‘When sleep puts an end to delirium, it is a good sign.’

‘Weariness without cause indicates disease.’

‘If there be a painful affection in any part of the body, and yet no suffering, there is mental disorder.’

‘To eat heartily after a long illness without putting on flesh is a bad portent.’

‘Food or drink slightly inferior in itself, but more pleasant, should be preferred to that better itself, but less pleasant.’

‘The old have fewer illnesses than the young, but if any become chronic with them they generally carry it with them to the grave.’

‘Those naturally very fat are more liable to sudden death than the thin.’

‘The dry seasons are more healthy than the rainy, and attended by less mortality.’

‘Cold sweats in conjunction with an acute fever indicate death, but with a milder fever only prolonged sickness.’

‘Convulsions supervening on a wound are deadly.’ (Tetanus, cp. p. 267.)

‘Those attacked by tetanus either die within four days, or if they get through these they recover’ (compare pp. 257 and 267).

‘Phthisis comes on mostly from eighteen to thirty-five years of age.’

‘It is fatal for a woman in pregnancy to be attacked by one of the acute diseases.’