Chapter XXIX: Section III: Constitution 2.699 (8)

[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 called _diastasis_, 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] The _maza_ was 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. See PAULUS 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.

Transcriber’s Notes:

1. Obvious printers’, punctuation and spelling errors have been corrected silently.

2. Where hyphenation is in doubt, it has been retained as in the original.

3. Some hyphenated and non-hyphenated versions of the same words have been retained as in the original.

4. Possible errors in Greek words or phrases have been retained as in original.

5. Italics are shown as _xxx_.