I can scarcely doubt but it will be generally admitted that the exposition of the subject here given is remarkably lucid, that our author’s divisions of it are strongly marked, and his rules of practice, whether correct or not, distinctly laid down. At all events, it will not be affirmed that there is any confusion in his ideas, or that his principles of treatment are not properly defined. After all that has been written on injuries of the head, it would be difficult to point to any better arrangement of them than that of our author, into five orders: 1st, simple fractures without depression; 2d, contusions without fracture or depression; 3d, depression with fracture; 4th, simple incisions without fracture; 5th, fractures par contre-coup.
As regards the operation of trepanning the skull, then, our author’s rule of practice is sufficiently well defined: we are to operate in the first two of these cases, that is to say, in simple fractures and contusions, but not in the last three, that is to say, in fracture with depression, in simple incisions in the skull, and in the counter-fissure. To begin, then, with the examination of those cases in which the operation is proscribed: it is not to be had recourse to in the counter-fissure, because, from the nature of it, there is generally no rule by which its existence can be positively ascertained, and therefore the case is to be given up as hopeless.
In the simple incision of the bone, that is to say, in the slash or indentation, when the effects of the injury are not transmitted to the brain, it must be obvious that all instrumental interference must be strongly contraindicated.[759]
At first sight it will appear remarkable to a surgeon, who approaches the subject with views exclusively modern, that our author should have interdicted the use of instruments in that class of injuries in which one would be inclined to suppose that they are most clearly indicated, namely, in a fracture of considerable extent, attended with depression of part of the bone from its natural level. Several questions present themselves here to be solved. Is the operation generally required? Has it been successful when it has been had recourse to? When it is to be performed, should it be done immediately, or not until the bad effects of the injury have manifested themselves?
With regard, then, to the necessity of the operation for depressed fractures, the most discordant opinions have prevailed in modern times, and even within a very recent period. Not to go farther back than Pott, it is well known that he established it as the general rule of practice, that in every case of fracture with depression, the skull should be perforated, and the depressed portion of the bone either raised to its level, or entirely removed. But since his time a great change of opinion has taken place on this subject, and of late it has become the general rule of practice (if rule can be predicated, where opinions are so vague and indeterminate) not to interfere, even in cases of depression, unless urgent symptoms have supervened. The late Mr. Abernethy took the lead in questioning the propriety of the rule laid down by Pott; and with the view of demonstrating that the operation may be often dispensed with in fractures complicated with depression, and in order, as he says, “to counteract in some degree the bias which long-accustomed modes of thinking and acting are apt to impress on the minds of practitioners,” he relates the histories of five cases of fracture with depression, which, in the space of twelve months, occurred under his own eyes in St. Bartholomew’s Hospital, and which all terminated favorably, although no operation was performed. These cases, supported by the authority of so great a name as Mr. Abernethy, made a deep impression on the profession, especially in this country, so that it became the established rule of practice in British surgery never to interfere in cases of fracture, unless with the view of removing urgent symptoms. See Cooper’s Surgical Dictionary, edit. 1825, and the previous edition. The old Hippocratic rule in regard to the trepan, when it is at all to be applied, namely, that of applying it as a preventive of bad consequences, was altogether eschewed, and it was held to be perfectly unwarrantable to perforate the skull, except with the intention of removing substances which were creating irritation and pressure of the brain. This practice, I say, was sanctioned by all the best army and hospital surgeons, from about the beginning of the present century, down to a very recent period. What, then, it will be asked, have been the results? Has experience confirmed the safety of this rule of practice, or has it not? To enable us to solve these queries, we have most elaborate and trustworthy statistics, published a few years ago by Dr. Laurie of Glasgow, which deserve to be seriously studied by every surgeon who may be called upon to discharge the duties of his profession in such cases. I cannot find room for long extracts from these valuable papers, but may be allowed to state a few of the more important results which are to be deduced from Dr. Laurie’s interesting investigation. Coming then at once to the point, it deserves to be remarked that Dr. Laurie’s ample experience has led him to reject decidedly the rule of practice, which, as I have stated, was established by Mr. Abernethy, about forty years ago, namely, that, in cases of depression, the symptoms of compression should be our guide to the employment of the trephine. He adds, “however well this rule may sound, when delivered ex cathedrá, it will be found of very little practical utility, for this reason, that if we limit interference to cases exhibiting symptoms of compression, we had much better not interfere at all, inasmuch as such cases prove almost invariably fatal. Such, at least, has been the experience of the Glasgow hospitals; for out of fifty-six cases operated upon, including, in point of time, a period little short of fifty years, there does not appear in our records a single unequivocal instance of profound insensibility, in which the mere operation of trepanning removed the coma and paralysis, or in any way conduced to the recovery of the patient. We wish to be clearly understood as speaking of the trephine used in reference to the state of the bone in cases of profound insensibility, not employed to remove extravasated blood. Nor does the cause of our want of success appear at all obscure. We believe that in practice the cases of urgent compression dependent on depressed bone alone are very few indeed; we are well aware that many such are on record, we do not presume to impugn their accuracy, we merely affirm that the records of the Glasgow Infirmary do not add to the number.” He thus states his views with regard to the principles by which the application of the trephine should be regulated. “From what we have said, it will appear that we coincide with these who, in using the trephine, in cases of compound fracture of the skull, look more to the state of the bone than to the general symptoms, and who employ it more as a preventive of inflammation and its consequences, than as a cure for urgent symptoms, the immediate result of the accident.” He goes on to state that “the details we have given are by no means in favor of the trephine. Of fifty-six cases operated upon, eleven recovered, and forty-five died. We feel assured that this affords too favorable a view of the actual results.”[760]
From the extracts now given, it will readily be seen that this very able authority has rejected entirely the rule of practice established by Mr. Abernethy, and that, in so far, he has reverted to the principle upon which the use of the instruments in simple fractures of the skull was regulated by Hippocrates, namely, as a preventive of the bad consequences of fracture on the brain, rather than with the view of relieving them when established. It will further be seen that, in whatever way applied, the use of perforating instruments in the case of depressed fractures is attended with so unsatisfactory results, that it may be doubted if any other operation in surgery, recognized as legitimate, be equally fatal.[761] Less than one fifth of the patients operated upon recovered. In fact, he very candidly admits “that it would not have been greatly to the disadvantage of the patients admitted into the Glasgow Infirmary, if the trephine had never found its way within its walls.” He further, in conclusion, adverts to the well-known fact that Desault, in the end, completely abandoned the operation, and that Mr. Lawrence states, “as far as the experience of this Hospital (St. Bartholomew’s) goes, he can cite very few instances in which the life of the patient had been saved by the operation of trephining.”[762]
Altogether, then, it will be allowed to no very questionable whether, in general, the Hippocratic treatment, in cases of fracture with depression, would not be fully as successful as the modern practice of perforating the skull. Moreover, it is by no means well ascertained, as generally assumed by superficial observers of facts in medical practice, that depressed fractures are more dangerous than other injuries of the skull attended with less formidable appearances. Indeed, recent experience has shown, in confirmation of the opinion advanced by our author, that extensive fractures, with great depression, are frequently not followed by any very dangerous train of consequences. (See Thomson’s “Observations made in the Military Hospitals of Belgium,” pp. 59, 60; Hennen’s “Military Surgery,” p. 287; Cooper’s “Lectures,” xiii.; Mr. Guthrie’s “Lectures on Injuries of the Head,” p. 56.) All these, in substance, coincide with Mr. Guthrie, who mentions with approbation that “it has been stated from the earliest antiquity, that the greater the fracture, the less the concussion of the brain.” I may mention further, that I myself, in the course of my own experience, have known many instances in which fractures with considerable depression were not followed, either immediately or afterwards, by any bad consequences; while, on the other hand, I have known cases in which simple contusion of the bone, without fracture or extravasation, and without even very urgent symptoms of concussion at first, have proved fatal in the course of a day or two. Now, in such circumstances, Hippocrates would have operated by either perforating the skull at once, down to the meninx, and removing a piece of it, or by sawing it nearly through, and leaving the piece of bone to exfoliate. It will be asked here, what object can he have had in view by this procedure? This he has nowhere distinctly defined; but, judging from the whole tenor of this treatise, and that of his commentator, Galen, I can have no doubt in my mind that what he wished to accomplish was to loosen the bones of the head, and give greater room to the brain, which he conceived to be in a state of congestion and swelling brought on by the vibration, or trémoussement, communicated directly to the brain by the contusion. It is, in fact, an opinion which Hippocrates repeatedly inculcates, not only with regard to the brain, but also respecting injuries of the chest and joints, that severe contusions are, in general, more dangerous than fractures, the effects of the vibration in the former case being more violent than in the latter.[763] Believing, then, that, in contusions, the internal structure of the brain is extensively injured, and that irritation, with hypertrophy, are the consequences, he advocated instrumental interference, in order as I have stated, to give more room to the brain, and relieve it from its state of compression.[764] This, no doubt, was the rationale of his practice also in simple fractures, not attended with depression, that is to say, his object in perforating the skull was to remove tension, and furnish an outlet to the collection within, whether of a liquid or a gaseous nature.
There can be no doubt that our author also had it in view, by perforating the skull, to afford an issue to extravasated blood and other matters collected within the cranium. This clearly appears from what is stated in section 18, and the same rule of practice is distinctly described by Celsus in the following terms: “Raro, sed aliquando tamen evenit, ut os quidem totum integrum maneat, intus vero ex ictu vena aliqua in cerebri membrana rupta aliquid sanguinis mittat; isque ibi concretus magnos dolores moveat, et oculos quibusdam obcæcet.... Sed ferè contra id dolor est, et, eo loco cute incisa, pallidum os reperitur: ideoque id os quoque excidendum est.” (viii., 4.) It is quite certain, then, that one of the objects for which our author recommended trepanning, was to give issue to extravasated blood on the surface of the skull. This naturally leads me to compare the results of modern experience in the treatment of cases of contusion, with or without extravasation of blood.
All the earlier of our modern authorities on surgery, such as Theodoric, Pet. c. Largelata, Ambrose Paré, Wiseman, and Fallopius, distinctly held that contusions of the skull, even when not complicated with a fracture, are often of so formidable a nature as to require the use of perforating instruments. The same views are strenuously advocated by Pott, who has described the effects of contusion in very elegant and impressive language. See page 42; ed. Lond. 1780. The upshot is, that one of the consequences of a severe contusion of the bone frequently is separation of the pericranium, “which is almost always followed by a separation between the cranium and the dura mater; a circumstance extremely well worth attending to in fissures and undepressed fractures of the skull, because it is from this circumstance principally that the bad symptoms and the hazard in such cases arise.” (p. 50.)[765] After insisting, in very strong terms, on the danger attending severe contusions of the, skull, he proceeds to lay down the rules of treatment, which, in a word, are comprehended in the two following intentions:—first, to prevent bad consequences by having recourse, at first, to depletion; and, second, to procure the discharge of matter collected under the cranium, which can be answered only by the perforation of it. He agrees with Archigenes that the operation is generally too long deferred, and that the sooner it is performed the better. Still, however, it is to be borne in mind that even Potts does not make it a general rule to operate at first, before the bad symptoms have come on, that is to say, during the first three days, and that he rather appears to have followed Celsus, who alludes to the method of Hippocrates, and describes his rule of practice in the following terms: