—“In omni vero fisso fractoque osse, protinus antiquiores medici ad ferramenta veniebant, quibus id exciderent. Sed multo melius est ante emplastra experiri, etc.... Si vero sub prima curatione febris intenditur, ... magni dolores sunt, cibique super hæc fastidium increseit; tum demum ad manum scalprumque veniendum est.” (viii., 4.) Pott then, it appears, follows the rule of Celsus, and does not operate until unpleasant effects have developed themselves;[766] but, at the same time, he candidly admits that, although the course now described be all that our art is capable of doing in these melancholy cases, he wishes he could say that it was frequently successful. He then goes on to relate several cases: first, of simple contusion without a wound; second, of contusion with a wound; and, third, of contusion with extravasation. In all these classes of cases he operated with very equivocal results; but then it is to be borne in mind, that, as I have said, he operated, like Celsus, after the bad effects had come on, and not, like Hippocrates, at first, in order to prevent them. Even with all these discouraging results, he continued to adhere to this rule of treatment, which, under the sanction of his name, became the established practice of the profession. The late Mr. Abernethy, who took the lead in innovating upon Pott’s rules for the application of the trephine, did not venture to make any material change in this case when he supposed that there was any considerable extravasation of blood; and he delivered it as a test whereby we might judge whether or not a great vessel had been ruptured within the skull, to examine whether or no the bone bled, having generally found, as, indeed, had been clearly laid down by Celsus, that in these cases the bone does not bleed. The rule of practice, then, to operate in order to remove the coagula of blood and matters which form between the skull and the dura mater, was sanctioned by Sir Charles Bell and Sir Astley Cooper; but they, like Mr. Abernethy, generally condemn interference when the fluids are situated below the membrane. On this subject Mr. Guthrie remarks:—“The operation of incising the dura mater, to admit of the discharge of blood or matter from beneath, and even of puncturing the brain, is much more commonly performed in France than in Great Britain, where it is very rarely had recourse to, and which may be an error,” etc. (p. 125.)
After thirty years’ further experience, this practice has been tested by the recent statistics of Dr. Laurie, and the results, as stated by him, are very discouraging. In the Hospital of Glasgow, it was found in practice that there was no certain symptom whereby it could be determined at what part of the head the blood had been effused, nor, when discovered, could it, in general, be removed by trephining the skull. The results, in short, were the following: “We have thus thirty-nine cases in which extravasation existed as the principal lesion, or as an important complication, in only one of which extravasation existed as the principal lesion, or as an important complication; in only one of which could an operation have saved the patient; and of the seventeen cases operated upon, not one recovered after, or was benefited by, the removal of the coagula.”
Such, then, are the results of modern experience, as far as they are at present ascertained, in the use of the trephine for the treatment of contusion, and undepressed fracture, complicated with the effusion either of blood or of matter, from the days of Pott down to the present time. The reader, however, should bear in remembrance that the practice, of which the results have been shown to be so unsatisfactory, is not that of Hippocrates, but of Celsus; for, in the present instance, even Dr. Laurie repudiates the idea of operating “for the purpose of relieving the evil consequences which may follow concussion of the brain,” and holds distinctly in this case that one is not warranted in even entertaining the idea of operating, unless—“first, when the puffy tumor indicates the spot which probably has sustained the greatest amount of injury; second, such an inflamed and suppurating condition of the injured soft parts as renders it more than probable that the corresponding portion of the dura mater is in a similarly diseased condition; third, inflammatory fever, preceded or followed by rigors, and symptoms of compression.” From what has been stated, then, it must appear evident that the recent statistics furnish no test whatever of the results of the practice laid down by Hippocrates, which was founded upon an entirely different principle, namely, the preventive.
But, however anxious I may feel to prosecute further this comparison of the results of ancient and of modern experience on this highly interesting subject, my necessary limits compel me to bring this discussion to a close. Before doing so, however, I shall briefly state the inferences which I think may be drawn from a careful study of all the principle authorities who have written on injuries of the head from Hippocrates down to the present time:
1. All the serious injuries of the skull may be arranged conveniently under the classes of contusions, simple fractures and fractures with depressions.
2. Hippocrates recommended the operation of perforating the cranium, in cases of simple fractures and contusions, whenever he apprehended that these would be followed by serious consequences, such as inflammation, extravasation of blood, and the effusion of matter.
3. Hippocrates operated in these cases during the first three days, before any serious symptoms had come on, but Celsus rejected this rule, and postponed the operation until after these effects had been developed.
4. The objects which Hippocrates had in view by perforating the skull, either entirely through or nearly so, would appear to have been to slacken the tightness of the skull, and procure the evacuation of extravasated blood lying within it.
5. The object for which Celsus opened the skull would appear to have been solely to remove bodies which were creating irritation in the brain.
6. All the ancient authorities looked upon contusions and simple fractures as being very formidable injuries, which generally produce congestion in the brain, with inflammation and effusion.