Hippocrates: On Head Wounds. Corpus Medicorum Graecorum I.4.1

Maury Hanson’s critical edition of Hippocrates’ De capitis vulneribus ( DCV) is a welcome and elegant addition to the growing number of Hippocratic publications that have appeared in recent decades. Specialists in ancient medicine, particularly those working on the Hippocratic corpus, will be indebted to Hanson (H.) for a job carried through with scholarly thoroughness and rigor. Published as volume I.4.1 of the Corpus Medicorum Graecorum series, the book contains the Greek text with a facing English translation, commentary, bibliography, introduction, and an index of Greek words. In this review, I touch on some of the features of the introduction and, generally, on H.’s edition, translation and commentary.

DCV can be described as a handbook of surgery whose purpose was to help physicians diagnose and treat different types of head injuries and make prognostications about them. The book opens with a bibliography, followed by an introduction, where H. discusses in detail the manuscript sources for the Greek text, previous editions and translations. In the discussion, the author addresses historical and philological problems posed by each MS, pointing out omissions, additions, errors and particularities of each text.

The oldest surviving MSS of DCV, B and V, date, respectively, to the tenth and twelfth century. From these two sources, H. reconstructs the textual tradition, comparing their contents. Despite the significant differences between them, these two MSS share several corrupt passages, which suggests descent from a common predecessor (p. 21). The Greek text presented in this edition is based on MS B, except for pp. 84.25-92.9, where V is more reliable (pp. 22, 35).

Based on the use of language, style and other syntactical criteria and external evidence, H. argues for a date of composition ca. 400 BCE (p. 52). His argument rests on the assumption that Epidemics V borrowed extensively from DCV. Since the proposed date for Epidemics V is no earlier than 336 BCE (p. 53), this date provides the terminus ante quem for DCV‘s composition. H. believes that, by the mid-fourth century BCE, DCV was already widely known.

Of particular interest in the introduction is H.’s discussion of the treatise’s posterity and its relationship to the Hippocratic corpus. H. notes many points in common between DCV and other Hippocratic treatises ( Epidemics V, Fractures, Places in Man etc.) (pp. 54f.), especially De ulceribus, whose similarities in language and content are so striking as to suggest a common author. He quotes several examples of similar passages in other Hippocratic writings, which would indicate either direct borrowing or, at least, a common intellectual environment, but H. draws no further conclusion regarding mutual influence, dependence or the chronology of these texts, excepting Epidemics V (p. 54). The author also reminds us of the affinities between Greek medical practice and Egyptian medicine. The contents of DCV have much in common with those in the Edwin-Smith papyrus (seventeenth century BCE, including the attention to clinical observation and the relationship between head injury and neurological dysfunction (p. 52). H. attributes these affinities to a long-standing tradition of exchange of ideas and practices in the eastern Mediterranean. This raises other interesting questions regarding the emergence, in ancient Greece, of a particular type of medical literature dealing with surgery and surgical techniques, which H. does not address.

Although DCV became influential in modern times, it was only rarely cited in antiquity (p. 55). This may indeed be due to the loss of Hellenistic literature on the subject (p. 55), but one wonders whether Galen’s knowledge and use of DCV would indeed confirm, as H. suggests, that this treatise remained a reference text in the treatment of head injuries into the second century CE and beyond (p. 55). Galen certainly knew of it, but Celsus and Paul of Aegina do not mention the treatise.¹ In fact, on many points of content these authors diverge from the Hippocratic text (pp. 56-7). One may perhaps attribute DCV‘s influence in later antiquity to the work of Galen and his commentaries on Hippocratic writings. Galen did write a commentary on DCV, which is not extant (p. 37), but is cited in other treatises and in Arabic sources (p. 37, n. 1).² Oribasius’ references to DCV seem also to have been lifted from that commentary (p. 38).

Of the treatise’s influence in the late medieval and post-medieval period, however, there should be no doubt.³ It is possible that a Norman collection of Hippocratic treatises containing DCV was given by Charles d’Anjou to Pope Clement IV in the thirteenth century. Since the eleventh century, there was a growing interest in ancient medical literature in southern Italy, not only in Sicily but also in Salerno, where several medical treatises were translated into Latin and commented upon.⁴ A copy of MS V was kept in the papal library in the fifteenth century (p. 17). It is difficult to ascertain the practical use of this treatise in the medieval period, as it was stored in those princely libraries. By the sixteenth century, however, it does seem to have become a work of reference in its field (pp. 46, 57). In that century alone, DCV was translated into five modern languages (p. 46). H. attributes the popularity of this work to its practical character in the context of pre-twentieth-century medicine. Yet one must also remember that an appeal to Hippocrates (and Galen), since the late Roman period, would have helped practitioners to enhance their reputation and to establish their authority.

DCV is divided into 21 chapters (p. 51). Calvus’ sixteenth-century Latin translation, based on the text of V (p. 44), opens with a preface, which is not found in the Greek manuscript tradition (p. 94). The source for this preface is unknown (p. 44), but its vocabulary suggests that it was not part of the original work (p. 95). Likewise, traces of an extension of the treatise were known in antiquity (to Galen at least), which have not survived (p. 51).

The treatise itself begins with an anatomical description of the skull and its sutures (chapters 1-2). The author then discusses the thickness of the skull and its relationship to the degree of injury (2-3); types of skull trauma (4-8); indications for trephination (9); the clinical evaluation of the patient (10-12); the treatment of different bone fractures (13-20); and finally, techniques of trephination (21).

The clinical evaluation and treatment of the patient constitute the bulk of the treatise. Great emphasis is placed on observation, on taking the patient’s history (chapters 11-12), and on teaching technical skills. There is a strong didactic quality to DCV, which it shares with Fractures, another Hippocratic treatise dealing with trauma. The description of trephination techniques shows this clearly (pp. 90-2, 117-9). Like Fractures, DCV is also remarkably devoid of explicit theorizing. Indeed, it lacks even that agonistic trait so common to ancient medical literature. The author of Fractures inveighs against “theorizing practitioners”,⁵ but in DCV one finds nothing of the sort. One would also have wished that H. had commented on this in the light of the ancient tradition of writing surgical treatises.

The practical nature of DCV is also apparent from the chapters dealing with clinical evaluation (chapters 10-12), whose purpose is to determine the extent of the injury, especially the degree of bone involvement. Because it might affect prognosis and treatment, diagnosing a bone fracture was always a priority in patients with head trauma (pp. 33ff., 64, 86-8). In cases where the extent of the injury was not clear, the author lays out in fine detail the recommendations for the use of a probe to explore the wound. In chapters 11 and 12, he describes the possible types of lesions (with or without fracture) associated with certain types of head trauma and weapons (11-12).

H. certainly deserves praise for the critical edition of the Greek text. Textual emendations are left to a minimum, and his reconstruction remains as close as possible to the transmitted text. The author often prefers the original to Littré’s emendations and offers new readings or interpretations of certain sections. For instance, in a difficult passage discussing the patient’s deterioration due to the doctor’s failure to trephine (chapter 19), Littré added the negative particle μή before ἐννοήσας (p. 116), making that failure, and the patient’s downhill course that issued from it, look like one of diagnosis. H. retains the transmitted text, without μή, thus implying that that failure was one of mismanagement, not of diagnosis.

In chapter 14, H. suggests that the author followed a peculiar grammatical construction often seen in recipes for medicines, which has δεῖ followed by an accusative-infinitive and infinitives with nominative particles. Where Littré had changed the nominatives to accusatives, H. retains the original, noting that the verb in the infinitive is used as an imperative (common in Hippocratic texts) and the particles modify the nominative subject of the infinitive (p. 113).

H. also offers new definitions for some terms. In a passage where the author of DCV recommends incising and opening up the wound for better visualization of the skull, the word ὑπόκοιλα is used to describe the wound. LSJ defines the term as “slightly concave”, using this very passage as an example. Instead, H. suggests that by that term the author meant a cavity or a hollow space formed between the scalp and the skull when the former was detached from the latter (pp. 110f.).

H.’s translation is clear and the commentary careful and thorough. He often explains the meaning of anatomical terms and physiological and pathological processes. Where the translation is problematic, H. justifies his choices, reminding us that sometimes the correct meaning must be obtained from the context, as with the term μῆνιγξ, which the author used indistinctively to signify both meninx and pericranium (p. 112). H. rightly translates ὑπερσαρκήσειε as the growth of “proud flesh”, an excess of granulation tissue arising from the healing of a wide or previously infected wound (p. 114). He draws a subtle distinction between the terms ὑπόπυον and διάπυον, the first meaning the onset of suppuration and the second suppuration at an advanced stage (p. 119). The commentary is full of such clarifications, which make it especially useful to those unfamiliar with Greek medical terminology. Abundant cross-references to other medical treatises add to its value.

Occasionally, however, H. seems too concerned to verify the “truthfulness” of the author’s statements by corroborating the ancient description of disease with modern medical pathology, as in his discussion of σπασμός associated with fractures in the temporal area of the skull. The ancient text states that contralateral seizures ( spasmos) can occur with wounds in the temporal area when the wound was incised. According to the ancient author, this was due to damage to the blood vessel crossing the area (p. 80). H. explains the author’s comments by reference to the instability of bone fragments yielding to the pressure of the surgeon’s hand, stimulating the cerebral cortex and resulting in seizure. This is certainly possible, but rare. The temporal cortex itself is not responsible for the motor functions of the limbs. And in most cases of temporal bone fracture, as H. himself reminds us, the bone is fixed.

Likewise, H. is right to say that as a complication of an infected head wound, spasmos probably means major motor seizures (pp. 111f.).⁶ As H. notes, the author’s use of the term σπασμός is rather vague (pp. 111f.). The word may describe different phenomena, from a simple involuntary twitch to a life-threatening full-blown motor seizure.⁷ Yet, to the ancient author and the medicine he practiced, making those distinctions was not an issue; spasmos only mattered because it was considered a “sign of death” (p. 88) and indicated a bad prognosis.

Another example of H.’s occasional attempt to explain the ancient text through modern categories is his suggestion that blisters in the tongue in the delirious patient whose condition was worsening may refer to herpes or aphthous stomatitis. This is possible, but the association of those lesions with head trauma would have been coincidental. On the other hand, dryness and chapping of the lips, tongue and oral mucosae with the formation of crusts is common in the comatose patient who is hyperventilating or breathing through the mouth. It is always tempting to try to find the correlation between the ancient disease and modern illness. The danger implicit in this search for modern equivalents, however, is that one may forget that diseases are also cultural constructs and lose sight of the way they are understood, perceived and interpreted in other cultures and times.

This is not the case with this volume. H. presents us with a fine work of scholarship, an important contribution to the study of ancient medicine, and a handsome addition to the CMG series. It should remain the standard reference edition for this Hippocratic treatise for a long time to come.

Notes

1. Galen mentioned the treatise three times: in the De officina medendi comm. 1.6 (p. 37); Comm. in Regimen in acute diseases (p. 57); De methodo medendi (p. 37). Paul of Aegina referred to it indirectly.

2. Oribasius’ allusions to DCV are in fact to Galen’s commentary on this treatise. See p. 38.

3. A copy of DCV may have existed in the library of the Norman kings of Sicily (p. 17), whence its fate was determined by the upheavals of southern Italy. The treatise might also have figured among the Hippocratic treatises translated into Latin by Bartholomew of Messina at the court of Manfred (p. 18).

4. See, for instance, K. Sudhoff, “Salerno: ein mittelalterliche Heil- und Lehrstelle am Tyrrhenischen Meere”, Archiv für Geschichte der Medizin 21 (1929), 43-62; P. O. Kristeller, “The School of Salerno: Its Development and Its Contribution to the History of Learning”, Bulletin of the History of Medicine 17 (1945), 138-196; H. P. Bayon, “The Masters of Salerno and the Origins of Professional Medical Practice”, in Science, Medicine and History: Essays on the Evolution of Scientific Thought and Medical Practice in Honor of Charles Singer, ed. E. A. Underwood (London, 1953), vol. 1, pp. 203-219; D. Jacquart, “L’enseignement de la médicine: quelques termes fondamentaux”, in Méthodes et instruments du travail intellectuel au moyen âge. Etudes sur le vocabulaire, ed. O. Weijers (Turnhout, 1990), pp. 104-120.

5. Hippocrates, Fractures 1.

6. However, they are not necessarily contralateral, as H. implies (pp. 111f.). Seizures associated with head trauma can often be generalized and result from cerebral edema.

7. It could also have meant “posturing,” a dramatic syndrome resulting from increased intra-cranial pressure.