Before concluding, I must also say a few words on one important point connected with the constitutional treatment, which the modern reader may at first sight be surprised to find no mention made of in this treatise—I mean the use of venesection in the treatment of injuries of the head. Now certainly it does not appear that Hippocrates regarded bleeding as necessarily forming a portion of the system of treatment in injuries of the bones of the head any more than in those of other bones. But, although these were his views, it can be as little doubted, by any one who is acquainted with his general views of practice, that he bled whenever the abstraction of blood was indicated, either to produce evacuation or revulsion. We know, for example, that in pains of the back part of the head he opened the temporal vessels,[769] and that in all inflammations and febrile diseases he abstracted blood freely, nay, perhaps, ad deliquium animi.[770] And that Hippocrates enforced the depletory system of treatment in injuries of the head, when pain and inflammatory fever supervened, is quite obvious, from its having been the system pursued in such cases by all subsequent authorities, who looked up to him as their great guide in practice. See Paulus Ægineta, Book VI., 90, Syd. Soc. Edit. I may mention further, as a proof that I am not straining a point in the present instance, in order, as might be supposed, to bring my author clear off in a case where he would appear to have been in fault, that Ambrose Paré, who is a great advocate for depletion in the treatment of fractures of the skull, is at great pains to show that he has Hippocrates on his side in support of this practice.[771] But while it is maintained that our author did not omit venesection when properly indicated, I did not mean to say that he or any of the ancient authorities carried the abstraction of the blood to the extent practiced by Pott, or the members of the Royal Academy of Surgery in France, nor as was done by the army and hospital surgeons of this country during the late war.[772] Whether or not this was a defect in ancient practice I shall not take it upon me to offer an opinion. Suffice it to say, that there is undoubted evidence that in injuries of the head the ancient surgeon, as is naively recommended by Avicenna, “bled his patient when he stood in need of being bled;”[773] that is to say, according to special indications, and not in obedience to any general rule.[774]
There is another point of practice in injuries of the head to which it is proper that I should draw attention—I mean cold applications. Now it is beyond a doubt that the application of cold in diseases of the brain is pointedly condemned by Hippocrates, and that he used hot applications instead;[775] and, moreover, that most of the ancient authorities adhered to his rule on this point. At the same time it would appear, that in extreme cases certain of them did not scruple to apply ice to the shaved head.[776] I shall only remark further, that in this case, as in diseases of the eyes, perhaps the safest rule is, to be guided very much by the feelings and habits of the patient.
[The Plates referred to will be found at the end of the work.]
ON INJURIES OF THE HEAD
1. Men’s heads are by no means all like to one another, nor are the sutures of the head of all men constructed in the same form. Thus, whoever has a prominence in the anterior part of the head (by prominence is meant the round protuberant part of the bone which projects beyond the rest of it), in him the sutures of the head take the form of the Greek letter tau, Τ; for the head has the shorter line running transverse before the prominence, while the other line runs through the middle of the head, all the way to the neck.[777] But whoever has the prominence in the back part of the head, in him the sutures are constructed in quite the opposite form to the former; for in this case the shorter line runs in front of the prominence, while the longer runs through the middle all along to the forehead.[778] But whoever has a prominence of the head both before and behind, in him the sutures resemble the Greek letter êta Η; for the long lines of the letter run transverse before each prominence while the short one runs through the middle and terminates in the long lines.[779] But whoever has no prominence on either part he has the sutures of the head resembling the Greek letter χ; for the one line comes transverse to the temple while the other passes along the middle of the head.[780] The bone at the middle of the head is double, the hardest and most compact part being the upper portion, where it is connected with the skin, and the lowest, where it is connected with the meninx (dura mater); and from the uppermost and lowermost parts the bone gradually becomes softer and less compact, till you come to the diploe.[781] The diploe is the most porous, the softest, and most cavernous part. But the whole bone of the head, with the exception of a small portion of the uppermost and lowermost portions of it, is like a sponge; and the bone has in it many juicy substances, like caruncles; and if one will rub them with the fingers, some blood will issue from them.[782] There are also in the bone certain very slender and hollow vessels full of blood. So it is with regard to hardness, softness, and porosity.
2. In respect to thickness and thinness; the thinnest and weakest part of the whole head is the part about the bregma; and the bone there has the smallest and thinnest covering of flesh upon it, and the largest proportion of brain is situated in that region of the head. And hence it happens that from similar or even smaller wounds and instruments, when a person is wounded to the same or a less degree, the bone of the head there is more contused, fractured, and depressed; and that injuries there are more deadly and more difficult to cure; and it is more difficult to save one’s life in injuries there than in any other part of the head; that from having sustained a similar or even a less wound a man will die, and that, too, in a shorter space of time than from a wound in any other part of the head. For the brain about the bregma feels more quickly and strongly any mischief that may occur to the flesh or the bone; for the brain about the bregma is in largest quantity, and is covered by the thinnest bone and the least flesh. Of the other portions, the weakest is that about the temples; for it is the conjunction of the lower jaw with the cranium, and there is motion there up and down as at a joint; and the organ of hearing is near it; and further, a hollow and important vein runs along the temple. But the whole bone of the head behind the vertex and the ear is stronger than the whole anterior part, and the bone itself has a larger and deeper covering of flesh upon it. And hence it follows, that when exposed to the same or even greater injuries from instruments of the same or greater size, the bone is less liable to be fractured and depressed than elsewhere; and that in a fatal accident the patient will live longer when the wound is in the posterior part of the head than when elsewhere; and that pus takes longer time to form and penetrate through the bone to the brain, owing to the thickness of the bone; and moreover, as there is less brain in that part of the head, more persons who are wounded in the back part of the head escape than of those who are wounded in the anterior part.[783] And in fatal cases, a man will survive longer in winter than in summer, whatever be the part of the head in which the wound is situated.
3. As to the hædræ (dints or marks?) of sharp and light weapons, when they take place in the bone without fissure, contusion, or depression inwards (and these take place equally in the anterior and posterior part of the head), death, when it does occur, does not properly result from them. A suture appearing in a wound, when the bone is laid bare, on whatever part of the head the wound may have been inflicted, is the weakest point of the head to resist a blow or a weapon, when the weapon happens to be impinged into the suture itself; but more especially when this occurs in the bregma at the weakest part of the head, and the sutures happen to be situated near the wound, and the weapon has hit the sutures themselves.[784]
4. The bone in the head is liable to be wounded in the following modes, and there are many varieties in each of these modes of fracture: When a wounded bone breaks, in the bone comprehending the fissure, contusion necessarily takes place where the bone is broken; for an instrument that breaks the bone occasions a contusion thereof more or less, both at the fracture and in the parts of the bone surrounding the fracture.[785] This is the first mode. But there are all possible varieties of fissures; for some of them are fine, and so very fine that they cannot be discovered, either immediately after the injury, or during the period in which it would be of use to the patient if this could be ascertained. And some of these fissures are thicker and wider, certain of them being very wide. And some of them extend to a greater, and some to a smaller, distance. And some are more straight, nay, completely straight; and some are more curved, and that in a remarkable degree. And some are deep, so as to extend downwards and through the whole bone; and some are less so, and do not penetrate through the whole bone.
5. But a bone may be contused, and yet remain in its natural condition without any fracture in it; this is the second mode. And there are many varieties of contusion; for they occur to a greater and less degree, and to a greater depth, so as sometimes to extend through the whole bone; or to a less depth, so as not to extend through the whole bone; and to a greater and smaller length and breadth. But it is not possible to recognize any of these varieties by the sight, so as to determine their form and extent; neither, indeed, is it visible to the eyes when any mischief of this kind takes place, and immediately after the injury, whether or not the bone has been actually bruised, as is likewise the ease with certain fractures at a distance from the seat of injury.[786]
6. And the bone being fractured, is sometimes depressed inwards from its natural level along with the fractures, otherwise there would be no depression; for the depressed portion being fractured and broken off, is pushed inwards, while the rest of the bone remains in its natural position; and in this manner a fracture is combined with the depression.[787] This is the third mode. There are many varieties of depression, for it may comprehend a greater and a smaller extent of bone, and may either be to a greater depth, or less so, and more superficial.[788]