[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 uses hedra in one place. (Meth. Med. vi.) The term hedra is rendered teli sedes by 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 the fractura per resonitum, that is to say, the fracture 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 by contre-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 fracture par 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 the rationale of 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 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.