7. In modern times, at least within the last hundred years, the trephine has never been applied in cases of contusion and simple fracture, upon the principle of the operation acting as a preventive of subsequent mischief, but only with the object of relieving effusion when it was supposed to have taken place within the cranium, that is to say, upon the plan recommended by Celsus.
8. The most contradictory accounts are given by modern authorities, especially by the French surgeons of the eighteenth century, as to the different results in cases of this description, when let alone, and when treated upon the Celsian principle; and the recent statistics of the operation are extremely unfavorable.
9. Hippocrates regarded fractures accompanied with depression and a considerable separation of the bones as being generally less dangerous than severe contusions and simple fractures, as in the former case the brain is usually less hurt by the vibration of the shock which inflicted the injury, and there is an outlet to any noxious matters which may get congested in the brain.
10. Hippocrates, as a general rule, did not operate in cases of depression, not even in cases of comminuted fracture, but in the latter case left the pieces of bone to separate gradually by suppuration.
11. Celsus, on the other hand, approved of removing spiculæ at once, of raising the depressed corner of a fractured bone, by sawing off the superincumbent part, and even of perforating the adjoining bone, and, in certain instances, of removing the whole of the depressed portion.
12. Pott laid it down as a general rule of practice, to operate with the trephine in all cases of fracture accompanied with any considerable degree of depression, and this formed the established practice in this country, until the late Mr. Abernethy, about forty years ago, introduced the rule of not interfering in such cases until urgent symptoms had come on.
13. Of late years a further innovation has taken place in this rule of practice in cases of depressed fracture, the operation being had recourse to by Dr. Laurie and others, on the principle of preventing the bad effects likely to result from the injury.
14. On whatever principle applied, the statistics of large hospitals exhibit the results of the operation in a most unfavorable light, insomuch that many of the most able and experienced surgeons of the day hesitate whether, as a general rule, the operation ought not to be abandoned altogether.
Finally, a careful study of the whole literature of the subject, from Hippocrates down to the present time, leads to the conclusion that what constitutes the great difficulty in the treatment of injuries of the head is, that the operation, to be successful, would require to be performed early, and rather with a view of preventing serious consequences, than of removing them after they have come on; and that these can seldom be estimated so correctly as could be wished, since they frequently bear no proportion to the apparent magnitude of the mischief which the cranium has sustained.[767]
As the reader may find some difficulty in apprehending correctly the nature of the instruments and other apparatus used by the ancients in surgical operations, I have subjoined drawings of them, taken principally from the works of Vidus Vidius and Andreas à Cruce, who both lived at a time when these instruments must have been sufficiently common in the cabinets of learned physicians, so that there is every presumption that the figures which they give are sufficiently correct. The manner in which they were used will readily be comprehended from their shapes, assisted by the following lucid description of the ancient process of trepanning the skull, given by Mr. Pott. “If the piece of bone intended to be removed was larger than could be comprehended within the modiolus (trephine?) then in use, and which was a very defective instrument in many respects, the operation was thus performed by means of terebræ. The piece intended to be taken away was surrounded with perforations made at small distances from each other, and then either the scalper excisorius or the scalper lenticulatus was introduced, and, by means of repeated strokes with a heavy mallet, was driven through all the interspaces between each perforation. By these means the portion of bone so surrounded was removed, and the dura mater was laid bare.”[768] That the modiolus of Celsus was a small circular saw with a pivot, exactly like the modern trephine, seems quite obvious from his own description of it; and that the instrument called by our author terebra serrata (πρίων χαρακτὸς) was identical with it, cannot admit of any doubt. See Foës, Œc. Hipp. in voce πρίων.