var. ὑγροκέφαλον
lat. hydrocephalus
Condition characterized by the accumulation of watery fluid (ὑδατῶδες ὑγρόν) in the head, as the name implies. The loci in which fluid gathers are three or four according to the sources. The ancient notion of hydrocephalus is considerably different from that of modern medicine and includes a broader range of medical afflictions. The ὑδροκέφαλον (πάθος) – the compound can be either a noun or adjective – has been recognized as a pathological and clinical condition since the days of Hippocrates, so that it has been clearly described by Greek and Latin physicians with investigation into its etiology, symptomatology, diagnosis, treatment and surgery. The only papyrological attestation of hydrocephalus is a medical catechism of the late II-beginning of the III century CE (GMP I 6), that is paralleled by the so called ‘continental’ tradition of the Latin Pseudo-Soranian Quaestiones medicinales (as is preserved in MS Carnot. 62, fol. 13r-v).
1-2. Etymology – General linguistic commentary
Descriptive compound formed from the Greek words ὕδωρ, ‘water’, and κεφαλή, ‘head’, expressing the cause and localization of the disease respectively, i.e. ‘water in the head’.[1] Both these nominal lexemes participate in a wide range of compound-nouns and adjectives as first or second component.[2] Some of them represent medical technical terms for diseases and discomfort, e.g. κεφαλγία, «headache» (LSJ9 945 s.v.), μυιοκέφαλον / μυοκέφαλον, «a complaint in the eyes, in which the uvea protrudes like a fly’s head» (LSJ9 1151 s.v.), ὑδροκήλη, «water in the scrotum, hydrocele» (LSJ9 1845 s.v.), ὑδρόμφαλον, «umbilical hernia supposedly due to accumulation of fluid» (LSJ9 1845 s.v.).
Even though the Greek compound ὑδροκέφαλον appears for the first time in the Latin Celsus ([3]) – with the somewhat problematic exception of [2] in the form ὑγρ- (vd. infra, C 1) –the Latin borrowing has only a few attestations: it is found in the abridged Latin version of Soranus’ Gynnaikeia by Muscio (XVII 29,10 [93,5 Rose] quaerendum est ne forte hydrocefalus sit hoc est aquam inter cutem capitis habeat)[3] and in the Latin translation of the Pseudo-Soranian Questiones medicinales ([7]), from which CGL III 601,37 Goetz igrocefalis fagolentus sanguis inter membranam et cutem is taken.[4] The word is spelled in different ways in the manuscript tradition of the Questiones medicinales: the neuter transliteration hydrocefalon in [7] and the masculine ydrocephalus (l. hydrocephalus Rose) in item 250 (An. II 273,25 Rose), drawn from the MS Cottonianus Galba E IV, and in item 336 in MS Lincoloniensis 220, fol. 39v.[5]
The only graphic variant of Greek ὑδροκέφαλον seems to be ὑγροκέφαλον,[6] as occurs also in other compounds where ὑδρο- and ὑγρο- are apparently semantic equivalents (even if the form in ὑγρο- is less attested), such as in the just mentioned case of ὑδροκήλη / ὑγροκήλη.[7]
The word does not spawn derivatives in the ancient languages.
According to LSJ9 1845 s.v., the compound is an adjective in [9], i.e. τὸ ὑδροκέφαλον πάθος, «the hydrocephalic / hydrocephalus condition», «the water-in-the-head affliction», implying that the neuter noun ὑδροκέφαλον is an abbreviated form for this, and perhaps the adjectival use is the older – although unattested previously [9] in our extant sources – and that the substantive has originally come into being through ellipsis of πάθος. The same structure is found in [10] and [11]. Some factors make clear the adjectival nature of ὑδροκέφαλος.[8] First of all the word-formation, since adjectives with κεφαλή as the second component end, as a rule, in -κέφαλος, several of which are attested in medical authors, e.g. ἁδροκέφαλος, ἀκέφαλος, ἀνεγκέφαλος, δικέφαλος, μακροκέφαλος, μεγαλοκέφαλος. From a syntactical point of view, another factor is word-order, since the position of the word ὑδροκέφαλος between definite article and its noun makes it an adjectival modifier of πάθος. Finally, the word is surely a noun-modifier in the expression τὰ ὑδροκέφαλα βρέφη, «hydrocephalic neonates», in Aët. XV 15,143 and 22,11-2 (74,2 and 121,6-7 Zervos), see also Sor. Gyn. IV 11, 3,3-4 (CMG VI 142,12-3 Ilberg) εἰ μὲν ὑγροκέφαλον εἴη τὸ βρέφος (corr. ὑδρ- in Ermerins’ edition [p. 290,16]), as well an in Paul.Aeg. VI 74, 3,7-8 (CMG IX 2, 116,20-1 Heiberg) ὑδροκεφάλου μὲν ὄντος τοῦ ἐμβρύου, «the foetus being hydrocephalic».
Furthermore, in modern Greek ὑδροκέφαλος, -η, -ο remains an adjective, along with ὑδροκεφαλικός, -ή, -ό, evidently formed in modern times, whereas ὑδροκεφαλία is the abstract formation.[9]
The noun ὑδροκέφαλον – phonetically and graphically adapted – lives on in medical technical terminology of other modern languages, which borrowed it directly from Greek or by way of later Latin, sometimes forming derivatives by adding suffixes. Examples are: English ‘hydrocephalus’ (also ‘hydrocephaly’) and derivatives ‘hydrocephalic’ and ‘hydrocephaloid’; Italian ‘idrocefalo’, ‘idrocefalia’, ‘idrocefalico’; German ‘Hydrozephalus’; French ‘hydrocéphalie’, ‘hydrocéphales’.
3. Abbreviation(s) in the papyri
No abbreviated form had appeared, as yet.
[1] Composition is one of the main strategies to create a technical terminology, see e.g. MAZZINI 1989, 19, 34-43; LANGSLOW 2000, 275-9; SCHIRONI 2010, 341-2.
[2] For the etymology and a list of some compounds, cf. BOISACQ, DELG 455 s.v. κεφαλή and 998-9 s.v. ὕδωρ; CHANTRAINE, DELG I 522 s.v. κεφαλή andII 1152-3 s.v. ὕδωρ; FRISK, GEW I 835-6 s.v. κεφαλή and II 957-9 s.v. ὕδωρ; BEEKES, EDG I 682-3 s.v. κεφαλή and II 15526-7 s.v. ὕδωρ. See also MAZZINI 1989, 65 nr. 119 “-cefal(o)” and 96 nr. 394 “-idr(o)-”.
[3] On Muscio and his Latin Genecia, see HANSON-GREEN 1994, 973,1030-1, 1046-57 with bibliography in n. 292.
[4] See TLL VI 3134,46-54 s.v.
[5] For discussion of the manuscript copies and their interrelationship, see FISCHER 1998, 1-54.
[6] It is found – and accepted by modern editors – in Sor. Gyn. IV 3, 1,4 and 11,3,4 (CMG IV 132,12 and 142,13 Ilberg) – but the second passage is corrected to ὑδρ- in Ermerins’ edition (p. 290,16. Cf. hydrocephalus in the Latin translation of Soranus by Musc. XVII 29,10 [93,5 Rose]) – and Alex. X (II 453,7 Puschmann). This form appears also in passages concerning medical problems in other authors, see e.g. [2] and Alex.Aphr. Pr. I 2,16 (I 6,21 Ideler), cf. ThGL IX 32B and LSJ9 1842 s.v. «suffering from water-on-the-head». Other possible variants or mistakes for the term are not reported in the critical apparatus of the medical authors in modern editions, with the exception of Paul.Aeg. VI 74, 3,7-8 (CMG IX 2, 116,20-1 Heiberg) ὑδροκεφάλου μὲν ὄντος τοῦ ἐμβρύου where cod. E attests ἀδροκεφάλου, i.e. «with large head» (LSJ9 24-5 s.v.): not a graphic variant but a word with quite similar meaning.
[7] See ThGL IX 32C-D s.v. ὑγροκήλη and 53Β-C s.v. ὑδροκήλη.
[8] One might also expect an adjectival form e.g. in -ικός, like κεφαλικός (see LSJ9 945 s.v.), i.e. ὑδροκεφαλικός, but it never occurs in ancient texts, even if attested in modern Greek (vd. supra). Furthermore, κεφαλικός is never used in the formation of compound words in ancient times. On the productivity of the suffix -ικός in technical terminology, particularly medical, see e.g. CHANTRAINE, FN 384-96; LIPOURLIS 2010, 1110-2; SCHIRONI 2010, 341. Likewise, compare ὑδρόμφαλον and its adjective ὑδρόμφαλος.
[9] See DIMITRAKOS, ΜΛ XIV 7368 s.vv.; BABINIOTIS, ΛΝΕΓ 1825 s.vv.; PAPYRAKI 1780 s.vv.
1.Hp. Morb. II 15 (X/2 149,1-150,7 Jouanna) – V-IV BCE
ἢν ὕδωρ ἐπὶ τῷ ἐγκεφάλῳ γένηται, ὀδύνη ὀξέα ἴσχει διὰ τοῦ βρέγματος καὶ τῶν κροτάφων ἄλλοτε ἄλλῃ, καὶ ῥῖγος καὶ πυρετὸς ἄλλοτε καὶ ἄλλοτε, καὶ τὰς χώρας τῶν ὀφθαλμῶν ἀλγεῖ, καὶ ἀμβλυώσσει, καὶ ἡ κόρη σχίζεται, καὶ δοκεῖ ἐκ τοῦ ἑνὸς δύο ὁρᾷν, καὶ ἢν ἀναστῇ, σκοτοδινίη μιν λαμβάνει, καὶ τὸν ἄνεμον οὐκ ἀνέχεται οὐδὲ τὸν ἥλιον, καὶ τὰ ὦτα τέτριγε, καὶ τῷ ψόφῳ ἄχθεται, καὶ ἐμεῖ σίελα καὶ λάπην, ἐνίοτε δὲ καὶ τὰ σιτία, καὶ τὸ δέρμα λεπτύνεται τῆς κεφαλῆς, καὶ ἥδεται ψαυόμενος. ὅταν οὕτως ἔχῃ, πρῶτον μὲν οἱ πιεῖν φάρμακον δοῦναι ἄνω ὅ τι φλέγμα ἄξει, καὶ μετὰ τοῦτο τὴν κεφαλὴν καθῆραι· ἔπειτα διαλείπων φάρμακον πῖσαι κάτω· ἔπειτα σιτίοισιν ἀνακομίζειν αὐτὸν ὡς ὑποχωρητικωτάτοισιν, ὀλίγα αἰεὶ προστιθείς· ἐπὴν δὲ κατεσθίῃ ἤδη τὰ σιτία ἀρκέοντα, ἐμέτοισι χρήσθω νῆστις, τῷ φακίῳ συμμίσγων μέλι καὶ ὄξος, λάχανα προτρώγων, καὶ τῇ ἡμέρῃ ταύτῃ ᾗ ἂν ἐμέσῃ, πρῶτον μὲν κυκεῶνα πινέτω λεπτόν· ἔπειτα ἐς ἑσπέρην σιτίοισιν ὀλίγοισι χρήσθω. καὶ ἀλουτείτω καὶ περιπατείτω ἀπὸ τῶν σιτίων καὶ ὄρθρου, φυλασσόμενος τὸν ἄνεμον καὶ τὸν ἥλιον, καὶ πρὸς πῦρ μὴ προσίτω. καὶ ἢν μὲν τοι ταῦτα ποιήσαντι ὑγιὴς γένηται· εἰ δὲ μή, προκαθήρας αὐτὸν τοῦ ἦρος πρῶτον μὲν ἐλλεβόρῳ, ἔπειτα ἐς τὰς ῥῖνας ἐγχέαι φάρμακον καὶ διαλείπων ὀλίγον χρόνον κάτω καθῆραι· ἔπειτα ἀνακομίσας σιτίοισιν, εἶτα ταμὼν τὴν κεφαλὴν κατὰ τὸ βρέγμα, τρυπῆσαι πρὸς τὸν ἐγκέφαλον καὶ ἰᾶσθαι ὡς πρῖσμα.
If fluid forms on the brain, violent pain is present between the forehead and temples, at one time in one place, at another time in another place, and from time to time there are chills and fever. The patient suffers pain in the sockets of his eyes, he sees unclearly, his pupil is divided, and he seems to see two things instead of one; if he gets up, dizziness comes over him; he can tolerate neither wind nor sun; his ears ring, he is vexed by any noise, and he vomits saliva and scum, sometimes food as well. The skin on his head becomes thin, and he feels pleasure on being touched there. When the case is such, first give the patient a medication to drink that will draw phlegm upwards, and after that clean out his head. Then, after an interval have him drink a medication to act downwards; next, restore him with foods of the most laxative kinds, continually adding a little more. When he has reached the stage where he is eating an adequate amount of food, have him employ vomiting in the fasting stage, by first eating vegetables, and then eating a decoction of lentils into which honey and vinegar have been mixed. On the same day he vomits, let him first drink a gentle cyceon, and then, towards evening, eat a little food; let him go without bathing, take walks after meals and early in the morning, yet staying out of the wind and sun. Do not let him approach any fire. If, when he does these things, he become well; if not, first clean him of water[1] by using hellebore, and then pour a medication into his nostrils; after an interval, clean him with a downward evacuation. Next, restore with foods, and then incise the head at the forehead; bore right through to the brain, and heal the wound as you would one made by sawing.
(Transl. P. Potter, slightly adapted [London 1988] 217-21)
2. Ps.-Arist. Pr. I 16,6-11 (861a,14-9 Bekker)
ὁ δὲ ἐγκέφαλος ὑγρός· διὸ καὶ ἡ κεφαλὴ ἀεὶ μάλιστα. δηλοῖ δέ, ὅτι αἱ τρίχες ἔνεισι μάλιστα ἐν αὐτῇ. ἡ δὲ τοῦ τόπου τούτου ὑγρότης φθειρῶν ποιητική. δηλοῖ δὲ ἐπὶ τῶν παίδων· ὑγροκέφαλοί τε γάρ εἰσι, καὶ πολλάκις ἢ κορυζῶσιν ἢ αἷμα ποιεῖ ῥεῖν, καὶ φθεῖρας πλείους οἱ ἐν ταύτῃ τῇ ἡλικίᾳ ἔχουσιν.
The brain is moist; this is why the head too is always especially moist. This is clear, because hair is present especially on this part. And the moisture of this region is conducive to the production of lice. This is clear in the case of children: for they are moist-headed, and often have either a runny nose or a bloody nose, and those in this age group frequently have an abundance of lice.
(Transl. R. Mayhew, slightly adapted [Cambridge-London 2011] 19-21)
3. Cels. Med. IV 2,4-9 (CML I, 152,16-153,27 Marx) – I BCE-I CE
Inuenitur genus, quod potest longum esse; ubi umor cutem inflat, eaque intumescit et prementi digito cedit: ὑδροκέφαλον Graeci appellant. Ex his id, quod secundo loco positum est, dum leue est, qua si ratione curandum, dixi, cum persequerer ea, quae sani homines inbecillitate partis alicuius facere deberent (cf. I 4 [CML I 38,22-39,19 Marx]). Quae uero auxilia sunt capitis, ubi cum febre dolor est, eo loco explicitum est, quo febrium curatio exposita est (cf. III 10,1-2 [CML I 107,6-18 Marx]). Nunc de ceteris dicendum est. Ex quibus id, quod acutum est, idque, quod supra consuetudinem intenditur, idque, quod ex subita causa etsi non pestiferum tamen uehemens est, primam curationem habet, qua sanguis mittatur. Sed id, nisi intolerabilis dolor est, superuacuum est, satiusque est abstinere a cibo; si fieri potest, etiam potione; si non potest, aquam bibere. Si postero die dolor remanet, aluum ducere, sternumenta euocare, nihil adsumere nisi aquam. Saepe enim dies unus aut alter totum dolorem hac ratione discutit, utique si ex uino uel cruditate origo est. Si uero in his auxilii parum est, tonderi oportet ad cutem; dein considerandum est, quae causa dolorem excitarit. Si calor, aqua frigida multa perfundere caput expedit, spongiam concauam inponere subinde in aqua frigida expressam; unguere rosa et aceto, uel potius his tinctam lanam sucidam imponere aliaue refrigerantia cataplasmata. At si frigus nocuit, caput oportet perfundere aqua calida marina uel certe salsa, aut in qua laurus decocta sit; tum caput uehementer perfricare; deinde calido oleo implere, ueste uelare. Ergo etiam ubi causa incognita est, uidere oportet, refrigerantia magis an calfacientia leniant, et is uti, quae experimentum adprobarit. At si parum causa discernitur, perfundere caput, primum calida aqua, sicut supra praeceptum est, uel salsa, uel ex lauro decocta, tum frigida posca. Illa in omni uetusto capitis dolore communia sunt: sternumenta excitare, inferiores partes uehementer perfricare; gargarizare iis, quae saliuam mouent; cucurbitulas temporibus et occipitio admouere; sanguinem ex naribus extrahere; resina subinde tempora reuellere, et imposito sinapi exulcerare ea, quae male habent ante linteolo subiecto, ne uehementer adrodat; candentibus ferramentis, ubi dolor est, ulcera excitare; cibum permodicum cum aqua sumere; ubi leuatus est dolor, in balineum ire, ibi multa aqua, prius calida, deinde frigida per caput perfundi: si discussus ex toto dolor est, etiam ad uinum reuerti, sed postea semper antequam quicquam aliud aquam bibere. Dissimile est id genus, quod umorem in caput contrahit. In hoc tonderi ad cutem necessarium est; deinde inponere sinapi sic ut exulceret; si id parum profuit, scalpello utendum est. Illa cum hydropicis communia sunt: exerceatur, insudet, uehementer perfricetur, cibis potionibusque utatur urinam praecipue mouentibus.
There is a class which may become chronic, in which a humor inflates the scalp, so that it swells up and yields to the pressure of the fingers. The Greeks call it hydrocephalus. Of these forms, that mentioned second, while it is slight, is to be treated by the regimen I have stated when I was describing what healthy men should do in the case of weakness of any part. For pain in the head accompanied by fever the remedies have been detailed when describing the treatment of fevers in general. Now to speak of the rest. Of these the case that is acute, also that which surpasses ordinary limits, and that which is of sudden causation and although not deadly, is yet violent, has its primary remedy in blood-letting. But this measure is unnecessary, unless the pain is intolerable, and it is better to abstain from food; also from drink, when possible; if not possible, then to drink water. If, on the day following, pain persists, the bowels should be clystered, sneezing provoked, and nothing but water taken. For often, in this way, all the pain is dispersed within one or two days, especially if it has originated from wine or indigestion. But if there is little benefit from the above, the head should be shaved down to the scalp; then it should be considered what cause excited the pain. If the cause was hot weather, it is well to pour cold water freely over the head, to put on the head a concave sponge now and again with the cold water wrung out; to anoint the head with rose oil and vinegar, or better to put on absorbent wool saturated with the same, or else other refrigerant plasters. But if cold has done the harm, the head should be bathed with warm sea water, or at any rate salt and water, or with a decoction of laurel leaf, after which the head should be rubbed smartly, have warm oil poured on it, and then be covered up. Some even bandage up the head, some load it with neck-wraps and mufflers, and so get relief; warm plasters give help in other cases. Hence, even when the cause is unknown, it should be observed whether cooling or heating methods afford the more relief, and to make use of those which experience has approved. But if the cause is not known, the head should be bathed, first in warm water as noted above, or in salt and water, or in the laurel decoction, next in cold vinegar and water. For all long-standing pain in the head, the following are the general measures: to provoke sneezing; to rub the legs smartly; to gargle things which provoke salivation; to apply cups to the temples and occiput; to draw blood from the nostrils; to pluck upon the skin of the temples frequently by the aid of pitch plasters; to apply mustard in order to cause ulcers over the site of the pain, after having put a layer of linen over the skin to prevent violent erosion; to excite ulcerations by cautery, applied over the seat of the pain; to take food in great moderation, with water; after the pain has been relieved, to go to the bath, and there to have much water poured over the head, first hot, then cold; if the pain has been quite dispersed, the patient may even return to wine, but should always before anything else drink some water. The class in which humor collects upon the head is different. In that case it is necessary to shave the head to the scalp; then to apply mustard until it causes ulcers; if this is of little avail, recourse must be had to the scalpel. The following measures are the same as for dropsical patients: exercise, sweating, smart rubbing, and such food and drink as will specially promote urination.
(Transl. W.G. Spencer [Cambridge 1971] 365-9)
4. Ps.-Gal. Introduct. 19,3 (91,21-92,4 Petit) – II CE[2]
ὑδροκεφάλων δὲ εἴδη τέσσαρα. τὸ μὲν μεταξὺ ἐγκεφάλου καὶ μήνιγγος. τὸ δὲ μεταξὺ μήνιγγος καὶ ὀστοῦ. τὸ δὲ μεταξὺ ὀστοῦ καὶ περικρανίου. τὸ δὲ μεταξὺ ὀστοῦ καὶ δέρματος.
There are four kinds of hydrocephalus: between the brain and the meninges, between the meninges and the skull, between the skull and the pericranium, between the skull and the skin.
5. Id. Introduct. 19,4 (92,9-13 Petit)
τὰ δὲ ὑδροκέφαλα τὰ μὲν ὑπὸ τὸ δέρμα καὶ τὸ περικράνιον δύο που ἢ τρισὶν εὐθείαις διαιρέσεσι κενοῦμεν. τὰ δὲ ὑπὸ τὰ ὀστᾶ ἐκκόπτοντες. τὰ δὲ μεταξὺ μήνιγγος καὶ ἐγκεφάλου ἀθεράπευτα.
We empty out the kinds of hydrocephalus between the skin and the pericranium with two or three straight incisions, those under the bones with excision, whereas those between the meninges and the brain are incurable.
6. Id. Def. med. 390 (XIX 442,15-7 K.)
ὑδροκέφαλον ἐστιν ὑδατώδους ὑγροῦ ἢ αἵματος τοῦ τρυγώδους συλλογὴ κατά τι μέρος τῶν τὴν κεφαλὴν πλεκόντων σωμάτων.
Hydrocephalus is the accumulation of watery fluid or thick blood in some part of bodies, involving the head.
7. Ps.-Sor. Quaest. med. 234-5 (as in MS Carnot. 62, fol. 13r-v, transcription by K.D. Fischer)[3]
234 Quid est hydrocefalon? aquati humores collectio uel sanguinolentum uel fecilentum semper tamen humidum.
235 Quot differentiae sunt in hycefalis? quattuor, enim inter cutem et omentum […] fit, et inter ipsum omentum […] fit, et inter omentum et testam, aut inter testam et miningam, aut inter miningam et cerebrum. fit autem huiusmodi collectio aut in parte aliqua capitis aut per totum.
234 What is the hydrocephalus? Accumulation of watery fluids, it is full of blood or dregs, yet always moist.
235 How many are the types of hydrocephalus? Four: it develops either between the scalp and the membrane (= pericranium) […], or into the same membrane […], or between this membrane and the skull, or between the skull and the meninx, or between the meninx and the brain. However, the accumulation occurs either in a part or in the entirety of the head.
8. GMP I 6,3-10 (LDAB 10278, MP3 2340.01, SoSOL 2011 454) – late II-beginning of the III CE
[τί ἐστι τὸ ὑγρὸν ὅν] | [ἔν τινι μέρει τῆς κεφ]α̣λῆς; | [τὸ πάθος προσαγορεύεται] ὑδροκέ[φαλον] | [διὰ τὸ ὑγρὸν ἐν κεφαλῇ συ]λλεγόμενον· | [πόσαι αἱ διαφοραὶ τῶν ὑδρ]ο̣κεφάλων; | [τέσσαρες ἢ γὰρ μεταξὺ τοῦ] δέρματος καὶ | [περικρανίου ἤ καὶ ὀ]σ̣τ̣οῦ ἢ μεταξύ | [ὀστοῦ καὶ μήνιγγος ἤ ἐγ]κεφάλου.
‘What is the moisture that is in some part of the head?’ The disease is called hydrocephalus because the moisture being collected in the head. ‘How many are the types of hydrocephalus?’ Four: either (1) between the scalp and the pericranium, or (2) [between the pericranium] and the skull, or (3) between the skull and the meninges, or (4) [between the meninges and the] brain.
(Transl. HANSON-MATTERN 2001, 81)
9. Orib. Coll. XLVI 28 (CMG VI 2,1, 237,25-239,7 Raeder)– IV CE
τὸ ὑδροκέφαλον γίνεται πάθος, ἀφυῶς τῆς κεφαλῆς θλιβομένης ὑπὸ τῶν μαιῶν, ἔτι νεογνῶν ὄντων τῶν παιδίων· παρακολουθεῖ δὲ τοῖς ἐν τῷ πάθει ὄγκος πολὺς προμήκης περὶ τὴν κεφαλήν, αἶσχος οὐκ ὀλίγον παρεχόμενος. διαφοραὶ δὲ τῶν ὑδροκεφάλων εἰσὶ τρεῖς· ἢ γὰρ μεταξὺ τοῦ δέρματος καὶ τοῦ περικρανίου ἢ μεταξὺ περικρανίου καὶ ὀστέου ἢ μεταξὺ ὀστέου καὶ μήνιγγος· μεταξὺ γὰρ μήνιγγος καὶ ἐγκεφάλου συστῆναι ὑγρὸν ἀδύνατον· φθαρείη γὰρ ἂν πρότερον ὁ τοῦτο παθὼν πρὶν ἢ τὸ ὑδροκέφαλον συστῆναι πάθος. […] εἰ μὲν οὖν μεταξὺ δέρματός τε καὶ περικρανίου τὴν σύστασιν λάβοι τὸ ὑγρόν, εἰ μὲν σύμμετρον εἴη τῷ πλήθει, καὶ μικρὸς ὄγκος τυγχάνοι, μίαν διαίρεσιν κατὰ μέσον ἐμβλητέον, σύμμετρον τῷ μεγέθει πρὸς τὸν ὄγκον. […] εἰ δὲ μείζων ὁ ὄγκος εἴη, δύο καὶ πλείους διαιρέσεις ἐμβαλοῦμεν […]. εἰ δὲ μεταξὺ περικρανίου καὶ ὀστέου γένοιτο τὸ ὑγρόν, ὁ μὲν αὐτὸς τρόπος τῆς χειρουργίας παραληφθήσεται […]. εἰ δ' ὑπὸ τὸ ὀστοῦν συσταίη τὸ ὑγρόν, εἴτε σὺν διαστάσει ῥαφῶν, εἴτε ἄνευ διαστάσεως, ἀπαγορεύσομεν τὴν χειρουργίαν· τήν τε γὰρ μήνιγγα ἀμήχανόν ἐστι μὴ οὐχὶ κακῶς ὑπὸ τοῦ ὑγροῦ περιπλεομένην διακεῖσθαι, ἥ τε διάστασις τῶν ῥαφῶν ἀθεράπευτός ἐστιν. εἰ δὲ χωρὶς τῆς διαστάσεως (scil. ῥαφῶν) ἐξογκωθείη τὸ ὀστοῦν, καὶ ὣς ἀνωφελὴς ἡ χειρουργία· ἀνατρήσαντες γὰρ τὸ μὲν ὑγρὸν κομισόμεθα, τὴν δ' ἀμορφίαν τὴν γεγονυῖαν ἐκ τῆς ἐπαναστάσεως τοῦ ὀστοῦ καταστεῖλαι πῶς ἄν τις δυνηθείη; εἰ δέ τις πᾶν ἐθέλοι τὸ ἐπανεστηκὸς ὀστοῦν ἐκκόπτειν, γυμνώσει τὴν μήνιγγα πᾶσαν καὶ σπασμῷ τὸν κάμνοντα παραδώσει.
The condition called hydrocephalus occurs when the head is squeezed in an unnatural way by midwives at the time of birth. Who is affected by this disease has a voluminous and elongated tumor with considerable deformity around the head. There are three different kinds of hydrocephalus: between the scalp and the pericranium, between the pericranium and the skull, between the skull and the meninges, for the formation of fluid between the meninges and the brain is impossible to sustain. In such a case the person affected dies before the development of the condition called hydrocephalus. […] When fluid gathers between the scalp and the pericranium, if the quantity is moderate and the tumor is small, a single incision as big as the tumor must be made in the middle. […] If the tumor is more voluminous, we make two or more incisions […]. The same operation will be performed when fluid collects between the pericranium and the skull […]. If fluid collects under the skull, with or without distension of sutures, we forswear surgery, because the meninges are impossible to manage when they lie in a bad state surrounded by fluid; distension of the sutures cannot be treated at all. If the skull forms a prominence even without distension (scil. of the sutures), surgery is likewise useless, for while we displace fluid perforating through, how could anyone dissipate the deformity due to the upward movements of the skull? If someone wants to cut off all the prominent parts of the bone, he will totally denude the meninx and abandon his patient to convulsions.
10. Aët. VI 1 (CMG VIII 2, 123,1-125,3 Olivieri), cf. XV 12,1-80 (34,12-37,18 Zervos) – VI CE
περὶ ὑδροκεφάλων Λεωνίδου. τὸ ὑδροκέφαλον πάθος προσαγορεύεται ἀπὸ τοῦ ἐν τῇ κεφαλῇ ὑδατώδους ὑγροῦ συλλεγομένου […]. γίγνεται δὲ τοῦτο ἢ ἐξ ἀδήλου ἢ ἐκ προδήλου αἰτίας […]. συνίσταται δὲ τὸ ὑγρὸν ἐπὶ τῶν ὑδροκεφάλων ἢ μεταξὺ τοῦ δέρματος καὶ τοῦ περικρανίου ὑμένος ἢ μυὸς τοῦ κροταφίτου ἢ ὑπὸ τὸν περικράνιον ὑμένα μεταξὺ αὐτοῦ καὶ τοῦ τῆς κεφαλῆς ὀστοῦ ἢ ὑπὸ τὸ κρανίον μεταξὺ τῆς μήνιγγος καὶ τοῦ ὀστέου. οἱ δὲ πρὸ ἡμῶν φασι καὶ μεταξὺ τῆς μήνιγγος καὶ αὐτοῦ τοῦ ἐγκεφάλου συνίστασθαι, ὅπερ ἐστὶν ὀλέθριον […]. τῆς δὲ συλλογῆς ὑπὸ κρανίον γεγενημένης μεταξὺ τοῦ ὀστέου καὶ τῆς μήνιγγος κατ' ἀρχὰς ὀλίγου ὄντος τοῦ ὑγροῦ ἡ κεφαλὴ βαρύνεται καὶ σκοτισμοὶ γίγνονται συνεχεῖς καὶ αἱ αἰσθήσεις ἀμβλύνονται […]. ὅταν δὲ πλεονάσῃ τὸ ὑγρὸν, αἱ ῥαφαὶ τῆς κεφαλῆς διὰ τὸ πλῆθος διίστανται ἀπ' ἀλλήλων καὶ διὰ τοῦτο ἡ κεφαλὴ μεγάλη γίγνεται καὶ πρόδηλος ὁ τόπος τῆς συλλογῆς· τῷ γὰρ δακτύλῳ ἐπειγομένῳ εἴκει τὸ ὑγρόν. χειρουργία· κοινῶς μὲν οὖν ἐπὶ τῆς ὑπὸ τὸ δέρμα συλλογῆς καὶ τῆς μεταξὺ τοῦ περικρανίου ὑμένος καὶ τοῦ ὀστέου ταῖς αὐταῖς ἐπιβολαῖς χρώμεθα πρὸς τὴν τοῦ ὑγροῦ ἔκκρισιν καὶ μικροῦ μὲν τοῦ ὄγκου ὄντος διαίρεσις μία μικρὰ κατὰ τῆς τοῦ ὄγκου κορυφῆς διδόσθω, μείζονος δὲ τοῦ ὄγκου γεγονότος δύο ἢ τρεῖς ἢ πλείους διαιρέσεις διδόσθωσαν κατ' ἀναλογίαν τοῦ μεγέθους ἐν τοῖς καθ' ὑπόρρυσιν τόποις […]. δυνατὸν δὲ ἀπὸ τῆς τρίτης συνεργεῖν τῇ παρακολλήσει διά τινος τῶν κολλητικῶν ἐμπλάστρων κτλ.
The hydrocephalus condition is so calledfrom the accumulation of watery fluid in the head […]. It exists from either an unknown cause or from a known one […]. Fluid associated with hydrocephalus collects either between the skin and the membrane round the skull (= pericranium) or the temporal muscle, or under the pericranium between the membrane and the bone of the head, or under the skull between the meninx and the bone. Those before our time also say that this fluid gathers between the meninx and the brain itself, which is a lethal situation […]. When fluid collects under the skull between the bone and the meninx, and its quantity is little at the beginning, the head is weighed down, there is continuous dizziness and the senses weaken […]. But whenever fluid is overabundant, the sutures of the head separate from one another because of the quantity, the head grows bigger and the locus of the accumulation is known, as fluid yields to the pressure of the finger. Surgery: we commonly perform the same operations to remove fluid when it gathers under the skin and between the pericranium and the bone. When the tumor is small a single little incision must be made over the top of it, but when the tumor becomes bigger either two or three or more incisions in proportion to its extension are made in the region of the drainage […]. After the third day it is possible to contribute to the healing applying one of the plasters able to close up wounds.
11. Paul.Aeg. VI 3 (CMG IX 2, 46,9-47,14 Heiberg) – VII CE
τὸ ὑδροκέφαλον πάθος ὠνόμασται μὲν ἀπὸ τῆς ἰδιότητος τοῦ γινομένου ὑγροῦ ὑδατώδους τὴν οὐσίαν ὑπάρχοντος, γίνεται δὲ τοῖς παιδίοις κατ' αὐτὴν τὴν ἀπότεξιν ἀφυῶς θλιβομένης ὑπὸ τῶν μαιῶν τῆς κεφαλῆς ἢ ἐξ ἀδήλου αἰτίας […]. ἢ γὰρ μεταξὺ περικρανίου καὶ δέρματος συνίσταται τὸ ὑγρὸν ἢ μεταξὺ περικρανίου καὶ ὀστέου ἢ μεταξὺ ὀστέου καὶ μήνιγγος. […] μετὰ δὲ τὴν χειρουργίαν ἐκκρίναντες τὸ ὑγρὸν καὶ διαμοτώσαντες προσφόρως ἐπιδήσομεν καὶ ἄχρι τῆς τρίτης οἰνελαίῳ ἐπιβρέχομεν· μεθ' ἣν λύσαντες ἐμμότῳ θεραπεύσομεν ἀγωγῇ καί, εἰ χρονίζοι τὸ ὀστέον μὴ σαρκούμενον, ἐλαφρῶς αὐτὸ ξύσομεν.
The hydrocephalus disease is so named from the nature of fluid, it being of a watery consistency. It occurs in children due to their heads being squeezed in an unnatural manner by midwives during the birth, or from some unknown cause […]. Fluid is formed either between the pericranium and the skin, or between the pericranium and the skull, or between the skull and the meninx. […] After surgery, having evacuated fluid and applied bandages suitably, we will bind it up and soak it with wine mingled with oil until the third day; after that, having loosened the bandages, we will treat it by the application of tents, and, if the bone is slow to heal, we will scrape it lightly.
[1] The translation follows the conjecture τοῦ ὕδατος by Potter. τοῦ ἦρος ΘΜ (followed by Jouanna, see comm. p. 227): ἄνω Littré.
[2] For discussion of the chronology of this treatise, see PETIT 2009, XXXVI-LI, especially p. XLIII: «le fait que le métodique Antipatros soit connu et cité dans le Médecin nous invite à situer la rédaction du traité au milieu du duxième siècle au plus tôt».
[3] See HANSON-MATTERN 2001, 74 with n. 11.
1. ὑδροκέφαλον and its medical sources
Hydrocephalus was a common illness in antiquity, as confirmed by the finding of numerous hydrocephalic skulls dating from the period 2500 BCE to 500 CE,[1] such as a skeleton with a hydrocephalic cranium discovered in Saqqara dating back to the I Dynasty.[2] Maybe also the elongated skull of the pharaoh Akhenaton (XVIII Dynasty) was due to hydrocephalus, but it might even represent a symbolic artificial deformation.[3]
The earliest scientific description of hydrocephalus in Greek medical literature is found in a long passage ascribed to Hippocrates.[4] In [1] the compound ὑδροκέφαλον is not mentioned explicitly,[5] but the author refers to this condition with the periphrasis ὕδωρ ἐπὶ τῷ ἐγκεφάλῳ, ‘water on the brain’. After the list of clinical symptoms and signs such as violent headache, chills and fever, visual disturbance, dim-sightedness, intolerance for sounds and vomiting, he focuses on the treatment and recommends specific diets, purges, sneeze-inducing inhalants and medications. Surgery is considered an intervention of last resort, i.e. an incision at the forehead and trephination to the brain, thus suggesting the locus where ‘water’ lurks and the way it might be drained. The proposal to empty out fluid by means of perforation along that part of the skull is evidence of the fact that hydrocephalus being described is an external form. According to GIJERRIS-SNORRASON 1991, 290 «Hippocrates’ medical and surgical treatment was the first of combined therapeutic proposals».
The first attestation of the compound occurs in [2] in the form ὑγροκέφαλος. Even if it is likely that the variant ὑγροκέφαλος is semantically equivalent to ὑδοκέφαλος in the other medical texts (vd. supra, A 1-2),[6] the term seems to acquire a more generic value here. Thus, it might be referred not to hydrocephalic disease but to the fact that children are general considered to possess moist heads. This may suggest that the compound does not represent an actual terminus technicus in the Aristotelian passage and that it is simply used in a literal way. The context itself seems to lead to this impression, and the use of assertions such as ὁ δὲ ἐγκέφαλος ὑγρός· διὸ καὶ ἡ κεφαλὴ ἀεὶ μάλιστα and ἡ δὲ τοῦ τόπου τούτου ὑγρότης φθειρῶν ποιητική. δηλοῖ δὲ ἐπὶ τῶν παίδων, when coupled with the ancient notion that moisture is the cause of lice,[7] suggests that the discussion focuses in a general way and does not intend a specific case of hydrocephalus.
The earliest extant attestations of the noun in its more usual form ὑδροκέφαλον date back to the I cent. CE. The term is mentioned only once in Aret. SD II 1, 13,2 (CMG II 64,33 Hude) κεφαλὴν ἐπὶ ὑδροκεφάλῳ,[8] but the disease is previously named in [3] ὑδροκέφαλον Graeci appellant. Celsus gives an accurate description of this condition with its symptoms and causes.[9] Etiology influences treatment and hydrocephalus seems to be classified by type and perhaps, by Celsus’ time numbered. First of all, the chronic form is considered. It occurs when a humor causes the scalp to swell up, producing a tumor-like formation which indents when the finger presses down, and it is said to be ‘listed second’ (quod secundo loco positum est). Then the acute form, that is defined non pestiferum tamen vehemens, is described in detail with its therapy. Celsus records known causes (hot and cold weather) and unknown ones, recommending the most suitable treatments, such as drying medicaments and scarification. Finally, a different type of hydrocephalus in which humor collects into the head (dissimile est id genus, quod umorem in caput contrahit), requires surgery when drying therapies are ineffective. This kind, otherwise, is to be treated like dropsy, with exercise, sweating, diet and diuretics. The hydrocephalus referred to by Celsus, as well as by the majority of ancient medical sources (vd. infra), is an extracranial condition, caused by an extracerebral accumulation of fluid.
The Pseudo-Galenic author of the Introductio sive Medicus formulates the earliest anatomical-pathological classification of fluid collections in the head,[10] first naming the four loci in which fluid gathers, moving from innermost to outermost ([4]), then distinguishing treatments according to the locus of accumulation ([5]): two or three straight incisions are necessary to treat hydrocephalus between subcutaneous and infrapericranial area, whereas more invasive cutting is recommended to remove subcranial fluid. Finally, the kinds of hydrocephalusbetween the meninges and the brain are said to be incurable (ἀθεράπευτα, ὀλέθριον). Another Pseudo-Galenic work ([6]) provides the first definition of this condition as a συλλογὴ ὑδατώδους ὑγροῦ ἢ αἵματος τοῦ τρυγώδους, thus specifying the qualitative composition of fluids collecting in the layers – this is the likely meaning of the generic word σώματα, «bodies» – surrounding the head.
Late antique compendiasts gather elaborate accounts by previous physicians, whose writings have otherwise been lost. Oribasius ([9])[11] preserves the long account by the Greek surgeon Antyllus (II cent. CE).[12] The author does not give an etiological explanation of the affliction apart from the improper handling by midwives during birth. He especially focuses on: the shape of the tumor-like formation (ὄγκος); the three loci where humor gathers, moving from outermost to innermost, since a fourth accumulation (i.e. between the meninges and the brain) is said to be impossible (ἀδύνατος) because lethal; the appearance of the ὄγκος depending on the area of the head where fluid collects and related symptoms. Finally, he gives a detailed report on surgery in relation to the localization of fluid buildup (vd. infra, C 2).
Aëtius preserves two versions of the account on hydrocephalus by Leonidas (middle-end of the I cent. CE).[13] The two versions are quite similar in content, but the second one (in XV 12,1-80 [34,12-37,18 Zervos]), that is the only one explicitly mentioned by Photius (Bibl. cod. 221, 180b 5-9 Bekker), is more than 30 lines longer and much more detailed, especially in the section devoted to therapy and surgery. In [10], as in [6], the condition is defined as an accumulation of watery fluid (ὑδατώδες ὑγρόν), which is τρυγῶδες, «like lees or dregs, thick» (LSJ9 1830 s.v.), and δίαιμον, «bloody» (LSJ9 395 s.v.). The hydrocephalus that occurs from either known or unknown causes, is described as four types and the final one, that between the meninges and the brain, is deadly. Symptomatology is determined by the quantity of fluid and the area in which it gathers. So, the author divides the fluid buildup under the skull between the bone and the meninx into two different forms: if the fluid is sparse the head is heavy, there is dizziness and senses are weak, whereas when fluid is abundant the sutures distend and progressive enlargement of the head occur, the locus of the accumulation is obviously recognizable, as fluid yields to the finger’s pressure. Finally the author focuses on therapy and surgery. Aëtius refers to hydrocephalus also in other passages.[14] Doubtful, however, is the presence of the word hydrocephalus in XVI 23,41 (32,1 Zervos), a chapter by Philumenus[15] on the extraction of the foetus (ἐμβρυουλκία) and its dismemberment (ἐμβρυοτομία). The compound noun appears in Zervos’ edition of Book XVI (Leipzig 1901)εἰ δὲ ὑπερβάλλοι τῷ μεγέθει ἡ κεφαλὴ ἢ φύσει ἢ δι' ὑδροκέφαλον. Nonetheless Roberto Romano (Torino 2006), reconstructs the text by the collation of several manuscripts,[16] because judged Zervos’ edition unreliable. Romano’s simpler version of this passage omits explicit mention of hydrocephalus, i.e. the cause of the iargeness of the head «either by nature or because of the hydrocephalus»: εἰ δὲ ἐκβάλλοι τῷ μεγέθει ἡ κεφαλή (p. 312). The last of the compendiasts Paulus Aegineta presents an extract from an anonymous author ([11]),[17] similar in content to the accounts of the other physicians, providing definition, etiology, details on the shape of the tumor in relation to its location in the head, symptoms, treatment and surgery. Thus, when fluid is formed between the skin and pericranium the tumor is soft, the swelling elevated, readily yielding to touch and ultimately virtually painless; when it is located between the pericranium and bone the swelling is harder, yields more slowly and is more painful; when fluid collects between the meninx and bone the swelling yields only to strong pressure. In the last case the fluid escapes through the distended cranial sutures, the head enlarges, especially the forehead, the eyes are fixed and shed tears, and pain is greater; surgical treatment, however, is nonetheless not advisable. The loci of fluid accumulations are but three, moving from outermost to innermost. Among the causes mentioned is the rupture of one or more vessels and consequent conversion of the extravasated blood into an inert fluid (κατὰ ῥῆξιν ἀγγείου ἢ ἀγγείων καὶ εἰς ἀργὴν οὐσίαν τοῦ ἐκχυθέντος αἵματος μεταβεβλημένου): this is likely the reason why the ὑδατῶδες ὑγρόν is defined τρυγῶδες and δίαιμον, as already said.
Although the discussions on hydrocephalus preserved by the Byzantine compendiasts differ among themselves in terms of phraseology and vocabulary, from a medical point of view they are similar and refer to extracranial collections of liquid. Nevertheless, the concept of pernicious swelling (ὄγκος) in intracranial position is present.[18]
In late antiquity and in the early medieval period (900-1100 CE) Arab and Persian physicians, in particular Rhazes, Avicenna, Ali Abbas and Albucasis, continued to pass on the writings of Greek authors, including descriptions of hydrocephalus along with all the rest. For instance, Rhazes borrowed his report mostly from Antyllus ap. Oribasius and Paulus, whereas Avicenna reworked freely the accounts by Aëtius and Paulus. Furthermore, Albucasis, very much the surgeon, as well as a physician, devoted one of his treatises to neurosurgical diseases,[19] among which infantile hydrocephalus, due either to an excessive mechanical compression at birth or to other, unknown causes.[20]
The only papyrological evidence for hydrocephalus is [8],[21] a papyrus scrap containing a fragment of medical catechism copied on the back of a roll previously used perhaps for accounts. Hydrocephalus is discussed in ll.3-18, and it is explicitly mentioned in ll.5 and 7.[22] The discussion is divided into three sections, each heading introduced by a question: the first set of question-and-response involves the definition of hydrocephalus (ll.3-6); the second set calls for differential diagnosis according to the four loci where fluid accumulation gathers, moving from outermost, the subcutaneous layer between scalp and pericranium, to innermost, that between the meninges and the brain (ll.7-10);[23] the final question (l.11) makes inquiry about the etiology of hydrocephalus and the response follows in ll.12-8, interspersing information on symptoms and treatment; little however can be read in these lines with confidence. As is the case with [5] τὰ δὲ μεταξὺ μήνιγγος καὶ ἐγκεφάλου ἀθεράπευτα and [9] διάστασις τῶν ῥαφῶν ἀθεράπευτός ἐστιν, the papyrus catechism eschews invasive procedures with the adjective ἀθεράπευτος in l.18. The compiler of this papyrus seems to have chosen sources similar to what is excerpted by the Byzantine compendists, probably the best information on the topic at their disposal. Nevertheless, no one of these Greek author seems to be the direct source of the papyrus. On the other hand, the text displays close affinities with the ‘continental version’[24] of the Latin Pseudo-Soranian Quaestiones medicinales ([7]) as preserved in a manuscript from Chartre, MS Carnot. 62, fol. 13r-v (X cent.).[25] Thus, it is likely that the source of this Latin translation was, at least in the section on hydrocephalus and perhaps also terêdôn, the Greek erôtapokrisis of which the papyrus is a lacunose copy.[26] Indeed, although the Latin translator omitted the etiology of hydrocephalus, the two texts have the same formal layout.[27]
As already pointed out, ancient medical writers usually list the loci of fluid accumulations from outermost scalp to innermost brain, although in [4] the order is reversed, from innermost to outermost. The loci are explicitly four in [7], perhapsfour in [8], while only three loci are explored in [9], the fourth being labelled as impossible for a patient to sustain, and thus fatal. In the same manner [10] focuses on three loci but mentions a fourth, labelling it lethal. [11] claims there are three loci, but omits the innermost, presumably because he too considers it untreatable.
Analysis of Greek and Latin sources reveals that the ancient notion of hydrocephalus is different from that in modern medicine, as disease descriptions from ancient physicians include a broader range of medical conditions, such as the babies with misshapen heads, or the hydroceles, the extracranial tumors, subdural hygromata, subcutaneous hematomas, etc. These are no longer regarded as a type of the disease hydrocephalus, while the ancient meaning of hydrocephalus as an extracranial affliction (vd. supra) does not overlap with modern hydrocephalus, a condition marked by abnormal accumulations of fluid in the cavities and lateral ventricles of the brain.[28] The ὑδατῶδες ὑγρόν of ancient authors is no doubt cerebrospinal fluid (CSF), a colorless bodily fluid produced from arterial blood by the choroid plexus; this fluid surrounds the brain and the spinal cord. Modern hydrocephalus, also termed ‘hydrodynamic CSF disorder’, results in progressive enlargement of the cranium due to raised intracranial pressure along the sutures of the skull. Hydrocephalus permanently damages the brain, posing risks to both physical and cognitive development. According to modern classification, hydrocephalus is either ‘communicating’ and ‘non-obstructive’, whenever a connection between the ventricles and the spinal subarachnoid space allows the CSF to pass from the brain to the spinal cord. Or it is ‘non-communicating’ and ‘obstructive’ when the flow of the cerebrospinal fluid is blocked in the ventricular system of the head. These two forms of hydrocephalus are sometimes congenital, i.e. present at birth, due to inherited genetic abnormality, and at other times acquired, i.e. developing at the time of birth or afterward. Symptoms of hydrocephalus include: neurological disorders such as mental retardation, epilepsy, convulsions; vomiting and nausea; headaches; lethargy and drowsiness; irritability or other changes in personality; poor coordination; blurred or double vision.
2. ὑδροκέφαλον in practice
In antiquity the first step in treatment of hydrocephalus involves modification of diet, dehydration cures, purgatives, diuretics, sneeze-inducing inhalants and medications, as is illustrated in particular by [1] and [3]. Only when these therapies do not succeed, do Celsus and the far earlier Hippocratic physician-author of Morb. II 15 (X/2 149,1-150,7 Jouanna) recommend surgery. Sometimes unguents and plasters are used to treat hydrocephalics. Aëtius gives us four examples of such therapeutic procedures: in [10] he claims that the third day after surgery one should apply an ἔμπλαστρος κολλητική, a ‘plaster able to close wounds’, in order to advance the healing process (see also Id.XV 12,42-3 and 71 [36,5-6 and 37,9 Zervos]). Aëtius prescribes a remedy that medicates both catarrh and hydrocephalus and this involves anointing the forehead with aσμῆγμακεφαλῆς made from sodium carbonate, iris, aristolochia, calamint and oxymel (VI 54, 9-13 [CMG VIII 2, 197,7-11 Olivieri); Aëtius also claims that a plaster made with Althaea officinalis and another made with capers heal hydrocephalic neonates (τὰ ὑδροκέφαλα βρέφη; XV 15,143 and 22,11-2 [74,2 and 121,6-7 Zervos]). Also Alex. X (II 453,7 Puschmann) refers to a remedy for hydrocephalics made with copper sulphate, sodium carbonate, aloe, white lead, oil and vinegar.
Ancient physicians give accurate accounts of surgery for hydrocephalics. The degree of surgical intervention depends upon the locus of the fluid accumulations and on the dimensions of the swelling produced by them. The type of hydrocephalus located most further within are considered incurable (ἀθεράπευτα). For instance, [5]recommends draining the hydrocephalic fluids out from under the skull by means of excision, but defines as ‘incurable’ the subcranial collection between the meninges and the brain, for it is often recognized as lethal (see e.g. [9] and [10]). On the other hand, [9] speaks favorably of surgery only in case of external accumulation (a single incision as big as the tumor itself if this remains small, and two or more incisions when it is more voluminous, see also Aëtius in [10]),[29] whereas if fluid collects beneath the skull he eschews surgery and claims that the operation is likewise useless when the swelling is without distension of the sutures. If, however, the physician cuts off the prominent parts of the bone denuding meninges, the patient will suffer of convulsions. A similar description is found in Paul.Aeg. VI 3, 2,1-12 (CMG IX 2, 47,3-14 Heiberg): when fluid gathers in the deep-down within (εἰς τὸ βάθος) and the whole head is distended (κεφαλὴ πᾶσα διίσταται), the author abandons all surgical intervention, although – he claims – some surgeons remove a piece of brain by trephination (τὴν χειρουργίαν ἀπαγορεύσομεν, εἰ καὶ μάλιστά τινες τῶν χειρουργῶν περιτρυπήσαντες ἐκομίσαντο τὸ ὀστέον); if fluid collects between the skin and the pericranium, and the swelling is small, he suggests to make one transverse incision through the middle (εἰ δέ γε μεταξὺ δέρματος καὶ περικρανίου συνίσταται τὸ ὑγρόν, μικροῦ μὲν ὄντος τοῦ ὄγκου μίαν διαίρεσιν κατὰ μέσον ἐγκαρσίαν ἐμβαλοῦμεν); finally, if the fluid is lodged between the pericranium and the skull, and the swelling is greater, two incisions intersecting one another in the middle are recommended, otherwise, in case it is even larger still, three incisions imitating the form of the Greek letter Η. This latter is an interesting detail unknown from the other sources (εἰ δὲ μεταξὺ περικρανίου καὶ ὀστέου, καὶ μείζων ὁ ὄγκος εἴη, δυσὶ κεχρήμεθα διαιρέσεσι τεμνούσαις κατὰ μέσον ἀλλήλας, εἰ δ' ἔτι μείζων, καὶ τρισὶ μιμουμέναις τὸ Η στοιχεῖον). Furthermore, post-operative instructions are also provided (see [11]): after having evacuated fluid and applied bandages, the author suggests binding up the wound and soaking it with wine and oil until the third day. Apply tents and scrape the bone lightly, if the bone heals slowly.
Useful for hydrocephalic surgery and resultant suppurations are also the reports adjacent in both ‘continental’ and ‘insular’ traditions of the Pseudo-Soranian Quaestiones medicinales:[30] chisel between the skin and the head for pouring out the accumulated fluid (inter cutem et testam incidimus et fundimus humorem), but if humor collects all around the head, then cut the whole head at intervals (per intervalla), so as to accomplish fluid evacuation. Make one or two incisions along the side (si autem circa totum fuerit caput, secamus quasdam partes totius vastitatis per intervalla ut inde defluat humor, et facimus unam incisionem vel duas in latum). Alternatively, when the buildup of fluid occurs under muscles, drain the humor by using a scalpel (cum autem sub musculis collection fuerit […] smiliario incidente humorem defluere facimus). Finally, the bandage labeled lepus sine auribus («hare without ears»), that is not referred to in any of the Greek accounts of hydrocephalus, is mentioned (utimur autem epidesmo cui est nomen lepus sine auribus).[31]
In sum, perforation and chiseling are the surgical procedures of choice and they are usually employed by ancient medical authors in discussions of surgery for hydrocephalus.
As to surgical implements, the instrument ordinarily employed is the scalpel, as in the aforementioned case, i.e. Greek σμιλάριον/σμίλη and Latin smiliarius.[32] For instance, Leonidas ap. [10] mentions a σμιλάριον, whose little handle (λαβίδιον) is used for safe surgical separation of tissue layers and muscle (Aët. VI 1,52-3 [CMG VIII 2, 124,28-9 Olivieri]: ἔπειτα ὑποδιαιρεῖν τὸ σῶμα διὰ τοῦ λαβιδίου τοῦ σμιλαρίου ἀσφαλῶς). Aetius mentions an alternative to the «common sclapel» (Aët. XVI 23,41-2 (32,1-2 Zervos): διελόντα αὐτὴν (sc. τὴν κεφαλήν) τῷ πολυτόμῳ σπαθίῳ ἢ τῷ κοινῷ σμιλίῳ, the everyday «cutting knife»; πολύτομον σπαθίον is the chisel to use on the head. Other (quite similar) surgical implements are referred to by Paul.Aeg. VI 74, 3,8-9 (CMG IX 2, 116,21-2 Heiberg): πολυπικῷ σπαθίῳ ἢ κατιάδι ἢ σκολοπομαχαιρίῳ κρυπτομένῳ κατὰ τοὺς δακτύλους τὸ κρανίον διελεῖν: a πολυπικὸν σπαθίον, «knife for removing polypi» (LSJ9 1442 s.v. πολυπικός), and a κατιάς, «lancet» (LSJ9 927 s.v., a σκολοπομαχαίριον, «a pointed surgical knife» (LSJ9 1613 s.v.).[33]
Hydrocephalus was routinely fatal until effective surgical techniques were generally made available, such as antisepsis, anesthesia, and the like. Even as late as the last decade of the nineteenth century and the first decades of the twentieth, no rational method of therapy had been discovered for hydrocephalics, and a record of successful surgical treatment for hydrocephalus was slow to be achieved. Indeed, many of the procedures now in use where conceived of in the early days of the twentieth century, such as the insertion of a shunt system and a ventricular catheter, a flexible but sturdy plastic tube, and a valve. Various types of cerebral shunts divert the excess of cerebrospinal fluid (CSF) into another bodily cavity, such as abdomen, peritoneum, even a chamber of the heart, or elsewhere into the circulatory system, where it can be safely drained and absorbed back into the blood stream.[34]
[1] Cf. RICHARDS-ANTON 1991, 165-200.
[2] Cf. BROTHWELL-SANDISON 1967, 428.
[3] Cf. SNORRASON 1946, 601-10 and GJERRIS-SNORRASON 1992, 285.
[4] Cf. GIJERRIS-SNORRASON 1992, 285-90; ASCHOFF-KREMER-HASHEMI-KUNZE 1999, 67; HANSON-MATTERN 2001, 75-6. On the Hippocratic Morb. II 12-75, that represents an early stage in the development of Greek medicine, see LANGHOLF 1990 21-5 and 52-72.
[5] So, the statement «the Hippocratic body of works also contains the first use of the term “hydrocephalus”» in ASCHOFF-KREMER-HASHEMI-KUNZE 1999, 67 is wrong. Had the authors written ‘the first appearance of the concept hydrocephalus’ one would have no quibble.
[6] As already mentioned, cf. in particular Sor. Gyn. IV 3, 1,4 and 11,3,4 (CMG IV 132,12 and 142,13 Ilberg) and Alex. X (II 453,7 Puschmann).
[7] See especially Arist. HA V 31 (556b 30-557a 8 Bekker) and Gal. De comp. med. sec. loc. I 7 (XII 462,8-15 K.).
[8] The chronology of Aretaeus of Cappadocia is uncertain, but probably his floruit should be placed in the mid-first century CE, cf. in particular OBERHELMAN 1994, 941-66 (especially p. 966). See also KUDLIEN 1967, 102 and NUTTON-REPPERT BISMARCK 1996b, 1051.
[9] Cf. PANDEL 1976, 38-9; GIJERRIS-SNORRASON 1992, 290; HANSON-MATTERN 2001, 76.
[10] Cf. PANDEL 1976, 32; GIJERRIS-SNORRASON 1992, 290; ASCHOFF-KREMER-HASHEMI-KUNZE 1999, 68; HANSON-MATTERN 2001, 77.
[11] The only other mention of hydrocephalus in Oribasius is Coll. XLVI 26 (CMG VI 2,1, 236,19-34 Raeder) = ibid. 18 (CMG VI 2,1, 224,26-225,9 Raeder) ὅσα εἴρηται ἐπὶ τῶν ὑδροκεφάλων, a cross-reference in a discussion of distension of sutures (τῶν ῥαφῶν διάστασις) that makes us know the existence of an account on hydrocephalus by the surgeon Heliodorus (I-II cent. CE), cf. GOSSEN 1912, 41-2; MARGANNE 1988, 107-11; TOUWAIDE-HEINZE 1998, 287-8.
[12] Cf. WELLMANN 1894, 2644-5 and NUTTON-REPPERT BISMARCK 1996a, 818.
[13] Cf. KIND 1925, 2034 and NUTTON-REPPERT BISMARCK 1999, 60.
[14] ὑδροκέφαλος is an adjective in the aforementioned passages XV 15,143 and 22,11-2 (74,2 and 121,6-7 Zervos), see supra, A 1-2.
[15] See DILLER 1941, 209-11.
[16] See ROMANO 2006, 261.
[17] The word occurs elsewhere only in Paul.Aeg. VI 74, 3,7-8 (CMG IX 2, 116,20-1 Heiberg) ὑδροκεφάλου μὲν ὄντος τοῦ ἐμβρύου .
[18] Cf. in particular Orib. Coll. XLVI 28, 5,1-2 (CMG VI 2,1, 238,5-6 Raeder) εἰ δὲ μεταξὺ μήνιγγος καὶ ὀστέου τὸ ὑγρὸν συσταίη, ὄγκος μὲν ἔσται κτλ. and Paul.Aeg. VI 3, 1,14-6 (CMG IX 2, 46,23-5 Heiberg) τοῖς δὲ μεταξὺ μήνιγγος καὶ ὀστέου ὄγκος μὲν ἔσται, ἀλλ' οὐχ ὑπείκων οὐδὲ ὁμοίως εὐαφής, πλὴν τῇ βιαίᾳ θλίψει ὠθούμενος εἴκει. See discussion in PANDEL 1976, 34-6 and 39-41.
[19] Book II, sect. 1 entitled De curatione aquae, in capitibus puerorum collectae in the Latin transcription of his Chirurgicorum omnium Primarii lib. tres.
[20] On Islamic medicine and hydrocephalus, see GIJERRIS-SNORRASON 1992, 292-3 and ASCHOFF-KREMER-HASHEMI-KUNZE 1999, 68.
[21] See HANSON-MATTERN 2001, 71-83; HANSON 2001, 305-10; HANSON 2003, 208-17.
[22] A first topic, maybe on calcification (πώρωσις), reaches its conclusion in l.2 (see HANSON-MATTERN 2001, 73 and. n. 7), whereas the last topic – the caries of the bones called τερηδών/terêdôn – is introduced in l.19 and is mentioned again in l.20 where the papyrus breaks off.
[23] For discussion of ll.7-10 and their restoration, see HANSON-MATTERN 2001, 82-3 comm. ad l.
[24] The manuscript tradition of the Ps.-Sor. Quaest. med. has been divided into two branches: MS Carnotensis 62 belongs to the so called ‘continental’ tradition, whereas the ‘insular’ tradition includes MS Cottonianus Galba E IV, fol. 238vb-244vb (early XIII cent.) and MS Lincoloniensis 220, fol. 22r-44r (XII cent.). On these manuscripts see FISCHER 1998, 1-54.
[25] The two copies of the ‘insular’ tradition do not spell out loci for fluid accumulations and focus instead on surgery for hydrocephalus (see items 250-1 [An. II 273,25-274,3 Rose, drawn from MS Cottonianus Galba E IV, and items 337-8 in Lincoloniensis fol. 39v), whereas in the ‘continental’ MS Carnotensis 62 (fol. 15r, items 271-2) the surgical discussion is separate, two folia subsequent.
[26] See HANSON-MATTERN 2001, 75 and 80.
[27] For the formal affinities between the medical catechisms on papyrus and the Ps.-Soranian Quaestiones medicinales, which often offers useful textual parallels, as in the present case, see HANSON 2003, 200-1 and LEITH 2009, 108.
[28] See PANDEL 1976, 41-6; GIJERRIS-SNORRASON 1992, 285; ARONYK 1993, 599-610; HANSON-MATTERN 2001, 75; PARKER-PARKER 2002.
[29] More detailed on surgical practice is Leonidas’ version in Aët. XV 12,28-80 (35,17-37,18 Zervos).
[30] Cf. item 251 (An. II 273,28-274,3 Rose). Close affinities in item 271 in MS Carnotensis 2, fol. 15r as transcribed by K.D. Fischer, see HANSON-MATTERN 2001, 78 n. 24 and HANSON 2003, 211 n. 34.
[31] Among Greek medical authors this kind of bandage is mentioned, e.g., by Heliodorus ap. Orib. Coll. XLVI 26, 2,6-7 (CMG VI 2, 236,11-2 Raeder) in form ὁ λαγωὸς ἐπίδεσμος, the «bunny bandage», in his discussion of distension of the sutures, for this bandage facilitates rejoining them, by Orib. XLVIII 26 and 7 (CMG VI 2, 276,17 and 29 Raeder) λαγωὸς χωρὶς ὤτων, the «bunny bandage without ears», and λαγωὸς σὺν ὤτοις, the «bunny bandage with ears», respectively (titles), by Sor. Fasc. 7,5 (CMG IV 160,17 Ilberg) λαγωὸς σὺν ὤτοις.
[32] semillarii is found in item 271, MS Carnotensis 62, fol. 15r, in the Pseudo-Soranian Quaestiones medicinales, whereas item 337, MS Lincoloniensis 220, fol. 39v and item 251 (An. II 273,36 Rose), drawn from MS Cottonianus Galba E IV, have smillario, corrected smiliario by Rose. On this implement, see GHIRETTI 2010, 61-3.
[33] On other instruments for penetrating the skull in ancient sources, see HANSON 2003, 214.
[34] For an historical review of the surgical treatment of hydrocephalus, see DAVIDOFF 1929, 1737-68; SCARFF 1963, 1-26; PUDENZ 1991, 15-26; ASCHOFF-KREMER-HASHEMI-KUNZE 1999, 70-93 with related bibliography.
ThGL IX 52D-53A s.v.; TLL VI 3133,46-54 ; LSJ9 1845 s.v.
DAVIDOFF 1929, 1737-68; SCARFF 1963, 1-26; PANDEL 1976, 30-47; TORACK 1982, 276-9; GIJERRIS-SNORRASON 1991, 285-312; PUDENZ 1991, 15-25; ARONYK 1993, 599-610; ASCHOFF-KREMER-HASHEMI-KUNZE 1999, 67-93; HANSON-MATTERN 2001, 71-83; PARKER-PARKER 2002.
GMP I 6,3-18 (the term is explicitly mentioned in ll.5 and 7) – SoSOL 2011 454.
Isabella Bonati