Chapter 35

[776]This is related of Philagrius in a very interesting scholium on the Aphorism just quoted. See Scholia in Hippocrat. et Galen., tom. ii., p. 457; ed. Dietz.[777]Perhaps the meaning here is, that when the forehead is much elevated, and the occiput much depressed, if one looks down upon the skull from above, the sagittal and coronal sutures will present the appearance of the letter Τ.[778]The meaning, I suppose, may be, that when the forehead is very low, and when the occiput is protuberant, if one looks down upon the skull from above, the sagittal and lambdoidal sutures will present the appearance of the letter Τ reversed.[779]The meaning would appear to be, that in a square-built head, that is to say, when it is prominent both before and behind, the coronal and sagittal sutures run nearly parallel to one another, and the sagittal connects them together in the middle. In this case they would present the appearance of the letter Η reversed.[780]Perhaps this alludes to the form of the head in which the sagittal suture passes through the middle of the os frontis down to the nose, in which case we may imagine that the coronal suture intersects the lambdoidal in such a manner as to have some resemblance to the letter χ. It is to be borne in mind, that the character of this letter was very variable in ancient writing. Ruffus Ephesius describes the sagittal suture as sometimes passing down the middle of the frontal bone.[781]This passage was considered by Scaliger as a gloss, but as interpreted by M. Littré, whom I have followed, the meaning is quite suitable. See his note, h. 1.[782]It is difficult to say what can be meant by caruncles in this place, but still I agree with M. Littré that Scaliger was not warranted in proposing to eject the passage from the text as an interpolation. Unless theglandulæ Pacchioniare meant (and the description must be admitted not to be quite applicable to them), I cannot pretend to explain or account for the description.[783]I need scarcely remark, that if by this is strictly meant that wounds in the posterior part of the head are less dangerous than those in the anterior, the statement is at variance with the experience of certain modern authorities. See, in particular, Pott and Liston, p. 46. At the same time, it is, no doubt, anatomically correct, that the occipital bone can bear more violence, without being seriously fractured, than the frontal or parietal bones, and it is worthy of remark, that the views and experience of Mr. Guthrie are very consonant with those of Hippocrates. He says: “The result of my experience on this point is, that brain is more rarely lost from the fore part of the head with impunity, than from the middle part; and that a fracture of the skull, with even a lodgment of a foreign body, and a portion of the bone in the brain, may be sometimes borne without any great inconvenience in the back part.... I have never seen a person live with a foreign body lodged in the anterior lobe of the brain, although I have seen several recover with the loss of a portion of the brain at this part. My experience, then, leads me to believe, that an injury of apparently equal extent is more dangerous on the forehead than on the side or middle of the head, and much less so on the back part than on the side. A fracture of the vertex is of infinitely less importance than one of the base of the cranium, which, although not necessarily fatal, is always attended with the utmost danger.” (On Injuries of the Head, p. 3.) I feel difficulty in reconciling these discordant results of modern experience. Perhaps the fact of the matter is, that injuries on the upper part of the occipital region are the least dangerous of any, whereas those in the lower part of it, are particularly fatal.[784]Vidus Vidius thus explains thehedraorsedes: “Inciditur os ita ut teli vestigium remaneat, quod genus fracturæ appellatur a Hippocrate ἒδρα, id est sedes, quum (ut ipse inquit) appareat in osse qua telum insederit; fit autem ab acuto telo, quod et ipse in sequentibus, et Galenus, in Commentario, in librum memoriæ prodidit, quum sub telo acuto incidi os dixit. Requirit autem sedes ut incisum os nullo modo ad cerebri membranam inclinatur.” (Chirurg. Græc., p. 71.) Andreas à Cruce defines it thus: “Potissimum vero sedes vocatur ubi osse in suo statu remanente qua parte telum insederit apparet.” (De Vulneribus, 1. 2.) Byhedrawould appear to have been understood a dint, or impression, left in a bone by a blow which has not produced fracture or depression. It was also applied to a cut or slash affecting only the outer plate of the skull. Hippocrates, it will be remarked, pronounces this sort of injury not to be dangerous of itself, but M. Littré relates a case taken from the “Journal de Médecine,” in which a sabre-cut, which only penetrated through the external plate of the cranium, and did not touch the internal, proved fatal. (Op. Hippocrat. iii., p. 170.) Our author, in the latter part of this paragraph, mentions cursorily injury of the skull at a suture, and more circumstantially in the twelfth paragraph. This accident is very correctly described by the later writers, under the name ofdiastasis. See Heliodorus (ap. Chirurg. Veteres, p. 100), and Archigenes (ibid., p. 117). Pott declares that he did not remember having ever seen a single instance of recovery when there was separation of the bones at a suture. Morgagni, in like manner, represents the case as being of a particularly serious character. (De Caus. et Sed. Morb.) I once saw a strongly marked case in which there was a considerable separation of the bones at the upper part of the temporal suture, along with an extensive wound, unguardedly inflicted by the scalpel of a juvenile surgeon, in order to explore the nature of the accident. As might have been expected, under these circumstances, the case had a fatal issue. Mr. Guthrie writes thus ofdiastasis: “It is well known, that when a violent shock has been received on the head, particularly by a fall on the vertex, the sutures are often separated to a considerable extent;these cases usually terminate fatally.” (p. 135.)[785]The meaning here is somewhat obscure, but as Arantius states in his commentary on this tract, our author probably means that a fissure is necessarily complicated with a contusion, or, in other words, that there can be no fissure without contusion.[786]Arantius and Porralius, in their conjoined commentary on this treatise, mention that in contusion sometimes only the outer plate of the skull is contused, but the inner is depressed upon the dura mater. This is a case of which we have examples in modern surgery; but it does not appear clearly to be alluded to in this place by our author. Mr. Guthrie, indeed, understands the ἀπήχημα of the Greek authors, andresonitusof the Latin, to apply to this variety of fracture; but he appears to me to be mistaken, for these terms unquestionable refer to thecontre-coup, of which we will treat presently. Quesnay, indeed, uses the termcontre-coupin this double sense, but, as I think, very injudiciously, as it tends to introduce confusion of ideas; for assuredly the case of a fracture on a different part of the head from that which received the blow, and a fracture on the inner plate of the skull from an injury on the outer, are quite different cases. See Quesnay, etc., p. 20, Syd. Soc. edit.[787]The expressions in this place are somewhat confused, but the meaning evidently is, that without fracture there can be no depression.[788]This third mode of fracture is thus defined by Celsus: “At ubi medium desedit, eandem cerebri membranam os urget; interdum etiam ex fractura quibusdam velut aculeis pungentibus,” (viii., 4.) Hippocrates, it will be remarked, makes no mention of spiculæ in his description of depression. Galen describes two varieties of depression; in the one the depressed portion retains its situation, and in the other it rises again to its former level. (De Caus. Morb.) Hippocrates does not appear to have been acquainted with the latter. Modern experience has shown that it sometimes occurs in children.[789]It is almost impossible to know what to make of this passage, owing to the corrupt state of the text.[790]The nature of this mode of injury is explained in the annotations on the third paragraph. It does not appear clear why our author has given two separate descriptions of this injury. He describes, it will be remarked, several varieties of it, according as it is complicated or not with contusion and fracture. Galen useshedrain one place. (Meth. Med. vi.) The termhedrais renderedteli sedesby the Latin translators of the Greek medical authors. (See Asellii Comment. in Hippocrat. de Vuln. Capit.) It is used also by Ambrose Paré, Wiseman, and all our earlier writers on surgery. Wiseman thinks the term most appropriate when applied to wounds inflicted by a pole-axe, halberd, or the like. (v. 9.) Paré applies it to a kind of injury, in which the bone is not broken through, but the print of the weapon is left on the skull. (xx., 7.) Fallopius gives an interesting discussion on it. (In librum Hippocrat. de Vuln. Capit.) The term incision, borrowed from Paulus Ægineta, has been since used in its stead. See Quesnay, on the Use of the Trepan, p. 29, Syd. Soc. edition; and on simple incisions or sabre-cuts, see, in particular, Mr. Guthrie, Injuries of the Head, p. 86.[791]This, it will readily be perceived, is thefractura per resonitum, that is to say, thefracture par contre-coup, or counter-fissure of modern authorities. Except Paulus Ægineta, I am not aware that any of the ancient authorities question the occurrence of this species of the accident, and with the exception of Vidus Vidius, Guido, Fallopius, and Dinus de Garbo, it is generally recognized by the best modern authorities, from Bertaphalia and Andreas à Cruce, down to Sir Astley Cooper and Mr. Liston. Mr. Guthrie, indeed, remarks, that in recent times there has been no well-authenticated instance of fracture on the one side of the head from a blow on the other. Such cases, however, are not wanting in the works of the earlier modern authorities. Quesnay writes thus: “We find in authors, also, many cases of fracture bycontre-coup, from one part of the head to the part opposite: and in honor of the ancients we may cite the case related by Amatus, who applied the trepan to the part of the head opposite to the wound, when he found that the symptoms were not relieved by applying it on the side wounded, and that the patient suffered from severe pain on the other side. This second trepan proved very apropos, for it allowed the escape of pus, which had collected under the skull.” (On the use of the Trepan.) All our modern authorities, including Mr. Guthrie, admit the reality of the case in which fracture of the base of the skull is produced by a blow on the upper part of the head. In imitation of our author, this case was denominated “infortunium” by the earlier authorities, such as Asellius and Porralius, being accounted an irremediable misfortune, because its seat could not be detected; and it is noticed in the following terms by Sir Astley Cooper, who did not trouble himself much about the writings of his predecessors, but formed his opinions from actual observation: “When the basis of the skull is fractured from a high fall, from the whole pressure of the body resting upon that part, on opening the brain and tearing up the dura mater, extravasated blood is commonly observed;this kind of fracture must inevitably prove fatal, nor can it be discovered till after death.” (Lectures, xiii.)[792]Whatever opinion may now be formed of the rule of practice here laid down, all must admit that it is clearly stated and distinctly defined. We have seen above that our author describes five modes of injury in the skull, namely, the incision or indentation, confined to its outer table; the contusion; the direct fracture; the fracturepar contre-coup; and the depression. He now states decidedly that it is only in the case of contusion and simple fracture, that the trepan can be applied with advantage. I have entered so fully into therationaleof this practice in the Argument, that I do not think it necessary to say more on the subject in this place.[793]This passage indicates strongly our author’s partiality for prognostics, or rather, I should say, for prorrhetics. It would appear to have been a primary consideration with him, in all cases, to secure the physician from blame, and to teach him how to gain the confidence of the patient and his attendants. Few who have practiced medicine for a great many years, will question the propriety of these rules of conduct, or doubt the importance of taking all honorable steps to ensure the confidence and good-will of patients and their friends.[794]There is a remark made by Arantius and Porralius on the latter part of this paragraph, which, although it appears to be scarcely warranted by anything in the text of our author, I quote for its importance, as showing that the earlier authorities were well aware of the danger and impropriety of treating injuries of the head in children by instruments: “Sed præ ceteris illud notandum quod dixerit (nudato osse) quasi dicat, eo non denudato quamvis calliso aut fisso, quod raro accidit, non esse tamen sectione denudandam calvariam: nam in pueris, ubi decidunt non raro accidit ut eorum collidatur calvaria, frangaturque, cute integra, quod etsi accidat, et tactu hoc probe precipiatur, sanguisque e venis effusus sub cute fluctua, abstinendum tamen a sectione est, neminem enim servatum vidi, cui sectio adhibita sit, propterea quod eorum calor facile dissipetur, eoque magis, quum gemitu et clamore caput valdè incelescat, et ad fluxiones suscipiendas proclive reddatur,” (Comm. in Hip. de Vuln. Cap.) It will be seen at § 18, that our author allowed the application of a small trepan in children when strongly indicated.[795]This passage is rendered as follows by Celsus: “Igitur, ubi ea percussa, protinus requirendum est, num bilem is homo vomuerit; num oculi ejus obcæcati sint; num obmutuerit; num per nores auresque sanguis ei effiuxerit: num conciderit, num sine sensu quasi dormiens jacuerit. Hæc enim non nisi osse fracto eveniunt; atque, ubi inciderunt, scire licet, necessariam, sed difficilem curationem esse.” (viii., 4.) Now, although it is no doubt true, as remarked by Pott (Injuries of the Head, § 4), that these symptoms sometimes take place, without there being any fracture of the skull, and that, on the other hand, as had been previously pointed out by Paré and Le Dran, fractures do sometimes take place without being accompanied by all these symptoms, still there can be no doubt that as a general rule the doctrine of Celsus is correct, and that, at all events, a case is to be treated as serious in which these symptoms occur. With regard to one of the characteristics of a fracture, thus noticed by Celsus, a modern authority of great experience, but little acquaintance with ancient learning, observes, “Blood flowing from the nose and ears is a symptom attending fracture of the skull. It may be consequent on mere concussion, a vibration which ruptures the membranes; but oftener it is a consequence of fissure across the bone.” (Institutes of Surgery, by Sir Charles Bell, vol., i, p. 173.)[796]The separation of the bones at a suture, usually calleddiastasis, is noticed in the annotations on § 8. I have also alluded, in my analysis of the Fifth Book of the Epidemics, to the case in which the author, generally supposed by ancient authorities to be Hippocrates, mistook a suture for a fracture of the skull. See Epidem. v., 14; and Celsus, viii., 4.[797]On the terms which occur parenthetically, the philological reader may consult the note of Stephanus, contained in the edition of Erotian by Franzius, under ἑδράιως. I may here remark, that it is difficult to account for the frequent repetition of these words in parentheses.[798]It will be remarked that, as a general rule, Hippocrates forbids us to apply the trepan at the sutures, but, notwithstanding this prohibition, it would appear to have been departed from in two cases related in the Sixth Book of the Epidemics. (See § 27 and 28.) The rule, however, to avoid the application of the trepan at the sutures, was generally observed by nearly all the modern authorities down to Pott, and even he admits that the sutures should be avoided when the trephine may with equal utility be set on any other part. Louis, in a paper lately reprinted from the Memoirs of the Royal Academy of Surgery, by the Sydenham Society, gives an interesting examination of the doctrine of the ancient and modern authors on this rule of practice. Most of the authorities quoted by him are averse to the application of the trepan over sutures, except when very urgently required. C. Porralius, in his marginal notes on Arantius’s Commentary on this work of Hippocrates, assigns three reasons for avoiding the sutures in this operation: 1st, because the bone is weak at that place; 2dly, because the membrane there being in close connection with the bone, is in danger of being injured; 3dly, because, by the contraction of the callus, the transpiration there will be stopped. The last of these reasons is based on the physiological doctrine of the ancient authorities respecting the uses of the sutures, one of which was, to permit transpiration from the brain. See Galen, de Usu Partium, ix., 1, 2.[799]Our author, it will be remarked, forbids liquid applications, tents, cataplasms, and bandages, in wounds of the head. He seems to have approved most of things of a drying nature. The other authorities would appear to differ considerably in their views regarding the proper principles upon which wounds on the head are to be treated. Celsus directs us, after laying bare the dura mater by trepanning, to apply strong vinegar to it, and when the membrane is inflamed, he approves of tepid rose-water. (viii., 4.) Paulus Ægineta, after the operation of trepanning, directs a piece of cloth, or small ball of wool dipped in oil, to be applied to the part. I believe they all agreed in rejecting sutures. See Galen, de Med. sec. Genera III.[800]Hippocrates would seem to hold the fanciful idea, that the forehead is environed by the rest of the head, and that afflux of blood takes place from the parts around to it. Scaliger rejects this passage as containing a doctrine wholly unworthy of our author.[801]The danger of incisions, in the temporal region, is adverted to in several parts of the Hippocratic Collection, as in the work On the Articulations, in the Prorrhetics, and the Coan Prænotions. Even at the present day, when the treatment of hemorrhage is better understood than in the days of the great Fathers of Grecian medicine, a large incision in that quarter is regarded with considerable apprehension. Convulsion, that is to say, tetanus, was supposed to be the frequent, if not the invariable, result of a wound in the temporal muscle. Pott, indeed, contends that lock-jaw is not necessarily produced by a wound there; he admits, however, that the application of the trepan to the temple is not often successful, but the reason of this he contends is, that in these fractures the breach generally extends to the base of the skull (§ 5). Quesnay, however, inclines to support the views of Hippocrates. (On the Use of the Trepan, p. 15, Syd. Soc. edit.) Scultet, in like manner, pronounces decidedly that a wound in the temple is a very dangerous affair. (Armam. Chirurg. Tabl. xxxi.)[802]Themazawas evidently a poultice prepared with barley-meal and vinegar, or water. See the Annotations on the treatise On Ancient Medicine.[803]Celsus translates this passage as follows: “At si ne tum quidem rima manifesta est, inducendum supra os atramentum scriptorium est, deinde scalpro id deradendum; nigritiem enim continet, si quid fissum est.” (viii., 4.) Arantius properly remarks, that the ancient ink must not be confounded with the modern, which is composed principally of copperas and galls. It was, no doubt, the milder kind prepared from the soot of pines with gum which was used in this case. On the writing-ink of the ancients, see Dioscorides (M. M., v., 182) and Pliny (H. N., xxxv., 6).[804]The text in the beginning of this paragraph is in a very unsatisfactory state. It seems pretty clear, however, that in this place our author describes caries of the bone brought on by an unhealthy state of the integuments. The description—allowance being made for the corruption of the text—is sufficiently distinct, and most probably has reference to that condition of the parts which is so graphically described by Pott as forming “a puffy, circumscribed, indolent tumour of the scalp, and a spontaneous separation of the pericranium from the skull under such tumour.”[805]Our author in this place would appear to treat of incipient hernia cerebri, as immediately before he treats of fungous ulcers on the pericranium. Galen in like manner, praises powerfully dessicant medicines upon the authority of Meges the Sidonian, who, he says, had great experience in these cases. He speaks of the plaster called Isis as being a most efficacious application to the dura mater, when laid bare. Its principal ingredients are of an escharotic and detergent nature, such as squama æris, burnt copper, ammoniac salts, myrrh, aloes, and the like. SeePaulus Ægineta, Vol. III., p. 564. Galen concludes his remarks on this subject with stating that, before getting into an inflamed state, the dura mater, as being of a dry nature, endures the most powerful medicines. (Meth. Med., vi., at the end.)[806]This description of a piece of bone which is going to exfoliate, is remarkably correct. Compare it with the following narrative: “A girl of ten or twelve years of age was struck on the head by an iron rod falling on her; the blow caused no wound, and the young woman was soon well, with the exception of a fixed pain of no great extent, which remained over one of the parietal bones. The pain continued for several years. M. Mareschal, who was at last consulted, considered it necessary to trepan. He exposed the bone at the painful part, and applied one crown of a trepan; he observed,that the bone, when sawed, appeared dry, like a skull that had been buried.” (Quesnay, on the Use of the Trepan.) This agrees excellently with the description given by Hippocrates. It is to be regretted, however, that the text here; as far as regards one word ἀποστρακὸς, is in a very unsatisfactory state. The conjectural emendation of Schneider (ἀπεσκληκὸς) seems to be a plausible emendation, but it is not adopted by Littré.[807]Our author delivers the same doctrine in the work On the Articulations, and states that extensive fractures of the bones are often less dangerous than others which appear not so formidable. I need scarcely remark that modern experience has confirmed the truth of this position. How often has it been seen that one patient died from a slight injury to the skull, while another recovered from an extensive fracture of it? Mr. Guthrie appears in so far to agree in opinion with our author, that extensive fractures are less dangerous than they appear; he says, “Mr. Keate, who has had great opportunities for observation in St. George’s Hospital, has invariably remarked that the symptoms dependent on extravasation have been less severe in the first instance, in proportion as the separation of the edges of the fracture have been greater one from the other, or when the sutures have yielded to the shock and have been separated. It has been stated from the earliest antiquity, that the greater the fracture, the less the concussion of the brain.” (p. 56.) See the Argument.[808]It will be remarked as a striking feature in our author’s views of practice in injuries of the head, not to interfere with fractures attended with depression. See the Argument, where the rationale of this practice is fully discussed.[809]Although these directions of our author regarding the treatment of children be most important, I am not aware that any other of the ancient authorities has shown his sense of their value of them by repeating them. It is well known that in children there is but one table, and that it is very thin. Our author, as remarked above, does not entirely omit the operation in the case of children, but uses a small trepan.[810]The reader will again remark an instance of our author’s fondness for prognosis, and his observance of the rule at all times to prevent the surgeon from committing himself by attempting hopeless cases. Celsus, writing in the same spirit, says, “Ante omnia scire medicum oportere, quæ vulnera insanabilia sint, quæ difficilem curationem habeant; ... non attingere,nec subire speciem ejus, ut occisi, quem sors ipsius intermit.” (v., 26.)[811]This is an opinion held by all the ancient authorities. Some interesting cases in point are related in the First Book of the Continens of Rhazes. It was explained on the principle that the cerebral nerves decussate. (See Aretæus, on the Causes of Disease, i., 7.) Modern experience, in the main, is in accordance with the ancient on this point. Paralysis has generally been found on the opposite side to that which has received the injury. See Thomson’s Observations, etc., p. 52; Larrey’s Mem. de Chirurg., iv., p. 180; Hennen’s Principles, p. 301.[812]This passage is thus translated by Celsus: “Si sub prima curatione febris intenditur, brevesque somni, et iidem per summa tumultuosi sunt, ulcus madet, neque alitur, et in cervicibus glandulæ oriuntur, magni dolores sunt, cibique super hoc fastidium increscit, tum demum ad manum scalprumque veniendum est.” (vii., 4.)[813]The practice advocated in this paragraph is alluded to by Paulus Ægineta, in his chapter on Fractures of the Skull. (vi., 90.)[814]The operation here described by our author is the more deserving of attention, as it appears to have been peculiar to him. It is not described by Celsus, Paulus Ægineta, Albucasis, nor any one of the ancient authorities, as far as I can find; neither am I aware of its having been attempted in modern times. The object of it, however, seems to be very rational, namely, to avoid doing serious injury to the dura mater by tearing the bone forcibly from it at once.[815]The instrument here used is named πρίων χαρακτὸς; and, as far as I can see, was the same as the modiolus of Celsus, and the χοινικὶς of the later authorities. It would certainly appear to have been a circular saw, and consequently not unlike our modern trephine. See the figures and the Argument.[816]The following sentence, taken from Sir Charles Bell’s description of the operation, looks like a translation of this passage of Hippocrates; but it is well known that our English surgeon was not guilty of reading Greek! “Withdraw your trephine from time to time, brush it, and run the flat probe round the circular cut.” The specillum of the ancient surgeons was, in most respects, not unlike our modern probe.[817]The meaning here would seem to be, that the bone does not extend so deep as might be supposed. See Foës, Œcon. Hippoc., under ἐπιπολαιότερον ὀστέου.

[776]This is related of Philagrius in a very interesting scholium on the Aphorism just quoted. See Scholia in Hippocrat. et Galen., tom. ii., p. 457; ed. Dietz.

[777]Perhaps the meaning here is, that when the forehead is much elevated, and the occiput much depressed, if one looks down upon the skull from above, the sagittal and coronal sutures will present the appearance of the letter Τ.

[778]The meaning, I suppose, may be, that when the forehead is very low, and when the occiput is protuberant, if one looks down upon the skull from above, the sagittal and lambdoidal sutures will present the appearance of the letter Τ reversed.

[779]The meaning would appear to be, that in a square-built head, that is to say, when it is prominent both before and behind, the coronal and sagittal sutures run nearly parallel to one another, and the sagittal connects them together in the middle. In this case they would present the appearance of the letter Η reversed.

[780]Perhaps this alludes to the form of the head in which the sagittal suture passes through the middle of the os frontis down to the nose, in which case we may imagine that the coronal suture intersects the lambdoidal in such a manner as to have some resemblance to the letter χ. It is to be borne in mind, that the character of this letter was very variable in ancient writing. Ruffus Ephesius describes the sagittal suture as sometimes passing down the middle of the frontal bone.

[781]This passage was considered by Scaliger as a gloss, but as interpreted by M. Littré, whom I have followed, the meaning is quite suitable. See his note, h. 1.

[782]It is difficult to say what can be meant by caruncles in this place, but still I agree with M. Littré that Scaliger was not warranted in proposing to eject the passage from the text as an interpolation. Unless theglandulæ Pacchioniare meant (and the description must be admitted not to be quite applicable to them), I cannot pretend to explain or account for the description.

[783]I need scarcely remark, that if by this is strictly meant that wounds in the posterior part of the head are less dangerous than those in the anterior, the statement is at variance with the experience of certain modern authorities. See, in particular, Pott and Liston, p. 46. At the same time, it is, no doubt, anatomically correct, that the occipital bone can bear more violence, without being seriously fractured, than the frontal or parietal bones, and it is worthy of remark, that the views and experience of Mr. Guthrie are very consonant with those of Hippocrates. He says: “The result of my experience on this point is, that brain is more rarely lost from the fore part of the head with impunity, than from the middle part; and that a fracture of the skull, with even a lodgment of a foreign body, and a portion of the bone in the brain, may be sometimes borne without any great inconvenience in the back part.... I have never seen a person live with a foreign body lodged in the anterior lobe of the brain, although I have seen several recover with the loss of a portion of the brain at this part. My experience, then, leads me to believe, that an injury of apparently equal extent is more dangerous on the forehead than on the side or middle of the head, and much less so on the back part than on the side. A fracture of the vertex is of infinitely less importance than one of the base of the cranium, which, although not necessarily fatal, is always attended with the utmost danger.” (On Injuries of the Head, p. 3.) I feel difficulty in reconciling these discordant results of modern experience. Perhaps the fact of the matter is, that injuries on the upper part of the occipital region are the least dangerous of any, whereas those in the lower part of it, are particularly fatal.

[784]Vidus Vidius thus explains thehedraorsedes: “Inciditur os ita ut teli vestigium remaneat, quod genus fracturæ appellatur a Hippocrate ἒδρα, id est sedes, quum (ut ipse inquit) appareat in osse qua telum insederit; fit autem ab acuto telo, quod et ipse in sequentibus, et Galenus, in Commentario, in librum memoriæ prodidit, quum sub telo acuto incidi os dixit. Requirit autem sedes ut incisum os nullo modo ad cerebri membranam inclinatur.” (Chirurg. Græc., p. 71.) Andreas à Cruce defines it thus: “Potissimum vero sedes vocatur ubi osse in suo statu remanente qua parte telum insederit apparet.” (De Vulneribus, 1. 2.) Byhedrawould appear to have been understood a dint, or impression, left in a bone by a blow which has not produced fracture or depression. It was also applied to a cut or slash affecting only the outer plate of the skull. Hippocrates, it will be remarked, pronounces this sort of injury not to be dangerous of itself, but M. Littré relates a case taken from the “Journal de Médecine,” in which a sabre-cut, which only penetrated through the external plate of the cranium, and did not touch the internal, proved fatal. (Op. Hippocrat. iii., p. 170.) Our author, in the latter part of this paragraph, mentions cursorily injury of the skull at a suture, and more circumstantially in the twelfth paragraph. This accident is very correctly described by the later writers, under the name ofdiastasis. See Heliodorus (ap. Chirurg. Veteres, p. 100), and Archigenes (ibid., p. 117). Pott declares that he did not remember having ever seen a single instance of recovery when there was separation of the bones at a suture. Morgagni, in like manner, represents the case as being of a particularly serious character. (De Caus. et Sed. Morb.) I once saw a strongly marked case in which there was a considerable separation of the bones at the upper part of the temporal suture, along with an extensive wound, unguardedly inflicted by the scalpel of a juvenile surgeon, in order to explore the nature of the accident. As might have been expected, under these circumstances, the case had a fatal issue. Mr. Guthrie writes thus ofdiastasis: “It is well known, that when a violent shock has been received on the head, particularly by a fall on the vertex, the sutures are often separated to a considerable extent;these cases usually terminate fatally.” (p. 135.)

[785]The meaning here is somewhat obscure, but as Arantius states in his commentary on this tract, our author probably means that a fissure is necessarily complicated with a contusion, or, in other words, that there can be no fissure without contusion.

[786]Arantius and Porralius, in their conjoined commentary on this treatise, mention that in contusion sometimes only the outer plate of the skull is contused, but the inner is depressed upon the dura mater. This is a case of which we have examples in modern surgery; but it does not appear clearly to be alluded to in this place by our author. Mr. Guthrie, indeed, understands the ἀπήχημα of the Greek authors, andresonitusof the Latin, to apply to this variety of fracture; but he appears to me to be mistaken, for these terms unquestionable refer to thecontre-coup, of which we will treat presently. Quesnay, indeed, uses the termcontre-coupin this double sense, but, as I think, very injudiciously, as it tends to introduce confusion of ideas; for assuredly the case of a fracture on a different part of the head from that which received the blow, and a fracture on the inner plate of the skull from an injury on the outer, are quite different cases. See Quesnay, etc., p. 20, Syd. Soc. edit.

[787]The expressions in this place are somewhat confused, but the meaning evidently is, that without fracture there can be no depression.

[788]This third mode of fracture is thus defined by Celsus: “At ubi medium desedit, eandem cerebri membranam os urget; interdum etiam ex fractura quibusdam velut aculeis pungentibus,” (viii., 4.) Hippocrates, it will be remarked, makes no mention of spiculæ in his description of depression. Galen describes two varieties of depression; in the one the depressed portion retains its situation, and in the other it rises again to its former level. (De Caus. Morb.) Hippocrates does not appear to have been acquainted with the latter. Modern experience has shown that it sometimes occurs in children.

[789]It is almost impossible to know what to make of this passage, owing to the corrupt state of the text.

[790]The nature of this mode of injury is explained in the annotations on the third paragraph. It does not appear clear why our author has given two separate descriptions of this injury. He describes, it will be remarked, several varieties of it, according as it is complicated or not with contusion and fracture. Galen useshedrain one place. (Meth. Med. vi.) The termhedrais renderedteli sedesby the Latin translators of the Greek medical authors. (See Asellii Comment. in Hippocrat. de Vuln. Capit.) It is used also by Ambrose Paré, Wiseman, and all our earlier writers on surgery. Wiseman thinks the term most appropriate when applied to wounds inflicted by a pole-axe, halberd, or the like. (v. 9.) Paré applies it to a kind of injury, in which the bone is not broken through, but the print of the weapon is left on the skull. (xx., 7.) Fallopius gives an interesting discussion on it. (In librum Hippocrat. de Vuln. Capit.) The term incision, borrowed from Paulus Ægineta, has been since used in its stead. See Quesnay, on the Use of the Trepan, p. 29, Syd. Soc. edition; and on simple incisions or sabre-cuts, see, in particular, Mr. Guthrie, Injuries of the Head, p. 86.

[791]This, it will readily be perceived, is thefractura per resonitum, that is to say, thefracture par contre-coup, or counter-fissure of modern authorities. Except Paulus Ægineta, I am not aware that any of the ancient authorities question the occurrence of this species of the accident, and with the exception of Vidus Vidius, Guido, Fallopius, and Dinus de Garbo, it is generally recognized by the best modern authorities, from Bertaphalia and Andreas à Cruce, down to Sir Astley Cooper and Mr. Liston. Mr. Guthrie, indeed, remarks, that in recent times there has been no well-authenticated instance of fracture on the one side of the head from a blow on the other. Such cases, however, are not wanting in the works of the earlier modern authorities. Quesnay writes thus: “We find in authors, also, many cases of fracture bycontre-coup, from one part of the head to the part opposite: and in honor of the ancients we may cite the case related by Amatus, who applied the trepan to the part of the head opposite to the wound, when he found that the symptoms were not relieved by applying it on the side wounded, and that the patient suffered from severe pain on the other side. This second trepan proved very apropos, for it allowed the escape of pus, which had collected under the skull.” (On the use of the Trepan.) All our modern authorities, including Mr. Guthrie, admit the reality of the case in which fracture of the base of the skull is produced by a blow on the upper part of the head. In imitation of our author, this case was denominated “infortunium” by the earlier authorities, such as Asellius and Porralius, being accounted an irremediable misfortune, because its seat could not be detected; and it is noticed in the following terms by Sir Astley Cooper, who did not trouble himself much about the writings of his predecessors, but formed his opinions from actual observation: “When the basis of the skull is fractured from a high fall, from the whole pressure of the body resting upon that part, on opening the brain and tearing up the dura mater, extravasated blood is commonly observed;this kind of fracture must inevitably prove fatal, nor can it be discovered till after death.” (Lectures, xiii.)

[792]Whatever opinion may now be formed of the rule of practice here laid down, all must admit that it is clearly stated and distinctly defined. We have seen above that our author describes five modes of injury in the skull, namely, the incision or indentation, confined to its outer table; the contusion; the direct fracture; the fracturepar contre-coup; and the depression. He now states decidedly that it is only in the case of contusion and simple fracture, that the trepan can be applied with advantage. I have entered so fully into therationaleof this practice in the Argument, that I do not think it necessary to say more on the subject in this place.

[793]This passage indicates strongly our author’s partiality for prognostics, or rather, I should say, for prorrhetics. It would appear to have been a primary consideration with him, in all cases, to secure the physician from blame, and to teach him how to gain the confidence of the patient and his attendants. Few who have practiced medicine for a great many years, will question the propriety of these rules of conduct, or doubt the importance of taking all honorable steps to ensure the confidence and good-will of patients and their friends.

[794]There is a remark made by Arantius and Porralius on the latter part of this paragraph, which, although it appears to be scarcely warranted by anything in the text of our author, I quote for its importance, as showing that the earlier authorities were well aware of the danger and impropriety of treating injuries of the head in children by instruments: “Sed præ ceteris illud notandum quod dixerit (nudato osse) quasi dicat, eo non denudato quamvis calliso aut fisso, quod raro accidit, non esse tamen sectione denudandam calvariam: nam in pueris, ubi decidunt non raro accidit ut eorum collidatur calvaria, frangaturque, cute integra, quod etsi accidat, et tactu hoc probe precipiatur, sanguisque e venis effusus sub cute fluctua, abstinendum tamen a sectione est, neminem enim servatum vidi, cui sectio adhibita sit, propterea quod eorum calor facile dissipetur, eoque magis, quum gemitu et clamore caput valdè incelescat, et ad fluxiones suscipiendas proclive reddatur,” (Comm. in Hip. de Vuln. Cap.) It will be seen at § 18, that our author allowed the application of a small trepan in children when strongly indicated.

[795]This passage is rendered as follows by Celsus: “Igitur, ubi ea percussa, protinus requirendum est, num bilem is homo vomuerit; num oculi ejus obcæcati sint; num obmutuerit; num per nores auresque sanguis ei effiuxerit: num conciderit, num sine sensu quasi dormiens jacuerit. Hæc enim non nisi osse fracto eveniunt; atque, ubi inciderunt, scire licet, necessariam, sed difficilem curationem esse.” (viii., 4.) Now, although it is no doubt true, as remarked by Pott (Injuries of the Head, § 4), that these symptoms sometimes take place, without there being any fracture of the skull, and that, on the other hand, as had been previously pointed out by Paré and Le Dran, fractures do sometimes take place without being accompanied by all these symptoms, still there can be no doubt that as a general rule the doctrine of Celsus is correct, and that, at all events, a case is to be treated as serious in which these symptoms occur. With regard to one of the characteristics of a fracture, thus noticed by Celsus, a modern authority of great experience, but little acquaintance with ancient learning, observes, “Blood flowing from the nose and ears is a symptom attending fracture of the skull. It may be consequent on mere concussion, a vibration which ruptures the membranes; but oftener it is a consequence of fissure across the bone.” (Institutes of Surgery, by Sir Charles Bell, vol., i, p. 173.)

[796]The separation of the bones at a suture, usually calleddiastasis, is noticed in the annotations on § 8. I have also alluded, in my analysis of the Fifth Book of the Epidemics, to the case in which the author, generally supposed by ancient authorities to be Hippocrates, mistook a suture for a fracture of the skull. See Epidem. v., 14; and Celsus, viii., 4.

[797]On the terms which occur parenthetically, the philological reader may consult the note of Stephanus, contained in the edition of Erotian by Franzius, under ἑδράιως. I may here remark, that it is difficult to account for the frequent repetition of these words in parentheses.

[798]It will be remarked that, as a general rule, Hippocrates forbids us to apply the trepan at the sutures, but, notwithstanding this prohibition, it would appear to have been departed from in two cases related in the Sixth Book of the Epidemics. (See § 27 and 28.) The rule, however, to avoid the application of the trepan at the sutures, was generally observed by nearly all the modern authorities down to Pott, and even he admits that the sutures should be avoided when the trephine may with equal utility be set on any other part. Louis, in a paper lately reprinted from the Memoirs of the Royal Academy of Surgery, by the Sydenham Society, gives an interesting examination of the doctrine of the ancient and modern authors on this rule of practice. Most of the authorities quoted by him are averse to the application of the trepan over sutures, except when very urgently required. C. Porralius, in his marginal notes on Arantius’s Commentary on this work of Hippocrates, assigns three reasons for avoiding the sutures in this operation: 1st, because the bone is weak at that place; 2dly, because the membrane there being in close connection with the bone, is in danger of being injured; 3dly, because, by the contraction of the callus, the transpiration there will be stopped. The last of these reasons is based on the physiological doctrine of the ancient authorities respecting the uses of the sutures, one of which was, to permit transpiration from the brain. See Galen, de Usu Partium, ix., 1, 2.

[799]Our author, it will be remarked, forbids liquid applications, tents, cataplasms, and bandages, in wounds of the head. He seems to have approved most of things of a drying nature. The other authorities would appear to differ considerably in their views regarding the proper principles upon which wounds on the head are to be treated. Celsus directs us, after laying bare the dura mater by trepanning, to apply strong vinegar to it, and when the membrane is inflamed, he approves of tepid rose-water. (viii., 4.) Paulus Ægineta, after the operation of trepanning, directs a piece of cloth, or small ball of wool dipped in oil, to be applied to the part. I believe they all agreed in rejecting sutures. See Galen, de Med. sec. Genera III.

[800]Hippocrates would seem to hold the fanciful idea, that the forehead is environed by the rest of the head, and that afflux of blood takes place from the parts around to it. Scaliger rejects this passage as containing a doctrine wholly unworthy of our author.

[801]The danger of incisions, in the temporal region, is adverted to in several parts of the Hippocratic Collection, as in the work On the Articulations, in the Prorrhetics, and the Coan Prænotions. Even at the present day, when the treatment of hemorrhage is better understood than in the days of the great Fathers of Grecian medicine, a large incision in that quarter is regarded with considerable apprehension. Convulsion, that is to say, tetanus, was supposed to be the frequent, if not the invariable, result of a wound in the temporal muscle. Pott, indeed, contends that lock-jaw is not necessarily produced by a wound there; he admits, however, that the application of the trepan to the temple is not often successful, but the reason of this he contends is, that in these fractures the breach generally extends to the base of the skull (§ 5). Quesnay, however, inclines to support the views of Hippocrates. (On the Use of the Trepan, p. 15, Syd. Soc. edit.) Scultet, in like manner, pronounces decidedly that a wound in the temple is a very dangerous affair. (Armam. Chirurg. Tabl. xxxi.)

[802]Themazawas evidently a poultice prepared with barley-meal and vinegar, or water. See the Annotations on the treatise On Ancient Medicine.

[803]Celsus translates this passage as follows: “At si ne tum quidem rima manifesta est, inducendum supra os atramentum scriptorium est, deinde scalpro id deradendum; nigritiem enim continet, si quid fissum est.” (viii., 4.) Arantius properly remarks, that the ancient ink must not be confounded with the modern, which is composed principally of copperas and galls. It was, no doubt, the milder kind prepared from the soot of pines with gum which was used in this case. On the writing-ink of the ancients, see Dioscorides (M. M., v., 182) and Pliny (H. N., xxxv., 6).

[804]The text in the beginning of this paragraph is in a very unsatisfactory state. It seems pretty clear, however, that in this place our author describes caries of the bone brought on by an unhealthy state of the integuments. The description—allowance being made for the corruption of the text—is sufficiently distinct, and most probably has reference to that condition of the parts which is so graphically described by Pott as forming “a puffy, circumscribed, indolent tumour of the scalp, and a spontaneous separation of the pericranium from the skull under such tumour.”

[805]Our author in this place would appear to treat of incipient hernia cerebri, as immediately before he treats of fungous ulcers on the pericranium. Galen in like manner, praises powerfully dessicant medicines upon the authority of Meges the Sidonian, who, he says, had great experience in these cases. He speaks of the plaster called Isis as being a most efficacious application to the dura mater, when laid bare. Its principal ingredients are of an escharotic and detergent nature, such as squama æris, burnt copper, ammoniac salts, myrrh, aloes, and the like. SeePaulus Ægineta, Vol. III., p. 564. Galen concludes his remarks on this subject with stating that, before getting into an inflamed state, the dura mater, as being of a dry nature, endures the most powerful medicines. (Meth. Med., vi., at the end.)

[806]This description of a piece of bone which is going to exfoliate, is remarkably correct. Compare it with the following narrative: “A girl of ten or twelve years of age was struck on the head by an iron rod falling on her; the blow caused no wound, and the young woman was soon well, with the exception of a fixed pain of no great extent, which remained over one of the parietal bones. The pain continued for several years. M. Mareschal, who was at last consulted, considered it necessary to trepan. He exposed the bone at the painful part, and applied one crown of a trepan; he observed,that the bone, when sawed, appeared dry, like a skull that had been buried.” (Quesnay, on the Use of the Trepan.) This agrees excellently with the description given by Hippocrates. It is to be regretted, however, that the text here; as far as regards one word ἀποστρακὸς, is in a very unsatisfactory state. The conjectural emendation of Schneider (ἀπεσκληκὸς) seems to be a plausible emendation, but it is not adopted by Littré.

[807]Our author delivers the same doctrine in the work On the Articulations, and states that extensive fractures of the bones are often less dangerous than others which appear not so formidable. I need scarcely remark that modern experience has confirmed the truth of this position. How often has it been seen that one patient died from a slight injury to the skull, while another recovered from an extensive fracture of it? Mr. Guthrie appears in so far to agree in opinion with our author, that extensive fractures are less dangerous than they appear; he says, “Mr. Keate, who has had great opportunities for observation in St. George’s Hospital, has invariably remarked that the symptoms dependent on extravasation have been less severe in the first instance, in proportion as the separation of the edges of the fracture have been greater one from the other, or when the sutures have yielded to the shock and have been separated. It has been stated from the earliest antiquity, that the greater the fracture, the less the concussion of the brain.” (p. 56.) See the Argument.

[808]It will be remarked as a striking feature in our author’s views of practice in injuries of the head, not to interfere with fractures attended with depression. See the Argument, where the rationale of this practice is fully discussed.

[809]Although these directions of our author regarding the treatment of children be most important, I am not aware that any other of the ancient authorities has shown his sense of their value of them by repeating them. It is well known that in children there is but one table, and that it is very thin. Our author, as remarked above, does not entirely omit the operation in the case of children, but uses a small trepan.

[810]The reader will again remark an instance of our author’s fondness for prognosis, and his observance of the rule at all times to prevent the surgeon from committing himself by attempting hopeless cases. Celsus, writing in the same spirit, says, “Ante omnia scire medicum oportere, quæ vulnera insanabilia sint, quæ difficilem curationem habeant; ... non attingere,nec subire speciem ejus, ut occisi, quem sors ipsius intermit.” (v., 26.)

[811]This is an opinion held by all the ancient authorities. Some interesting cases in point are related in the First Book of the Continens of Rhazes. It was explained on the principle that the cerebral nerves decussate. (See Aretæus, on the Causes of Disease, i., 7.) Modern experience, in the main, is in accordance with the ancient on this point. Paralysis has generally been found on the opposite side to that which has received the injury. See Thomson’s Observations, etc., p. 52; Larrey’s Mem. de Chirurg., iv., p. 180; Hennen’s Principles, p. 301.

[812]This passage is thus translated by Celsus: “Si sub prima curatione febris intenditur, brevesque somni, et iidem per summa tumultuosi sunt, ulcus madet, neque alitur, et in cervicibus glandulæ oriuntur, magni dolores sunt, cibique super hoc fastidium increscit, tum demum ad manum scalprumque veniendum est.” (vii., 4.)

[813]The practice advocated in this paragraph is alluded to by Paulus Ægineta, in his chapter on Fractures of the Skull. (vi., 90.)

[814]The operation here described by our author is the more deserving of attention, as it appears to have been peculiar to him. It is not described by Celsus, Paulus Ægineta, Albucasis, nor any one of the ancient authorities, as far as I can find; neither am I aware of its having been attempted in modern times. The object of it, however, seems to be very rational, namely, to avoid doing serious injury to the dura mater by tearing the bone forcibly from it at once.

[815]The instrument here used is named πρίων χαρακτὸς; and, as far as I can see, was the same as the modiolus of Celsus, and the χοινικὶς of the later authorities. It would certainly appear to have been a circular saw, and consequently not unlike our modern trephine. See the figures and the Argument.

[816]The following sentence, taken from Sir Charles Bell’s description of the operation, looks like a translation of this passage of Hippocrates; but it is well known that our English surgeon was not guilty of reading Greek! “Withdraw your trephine from time to time, brush it, and run the flat probe round the circular cut.” The specillum of the ancient surgeons was, in most respects, not unlike our modern probe.

[817]The meaning here would seem to be, that the bone does not extend so deep as might be supposed. See Foës, Œcon. Hippoc., under ἐπιπολαιότερον ὀστέου.

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