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 ON INJURIES OF THE HEAD.
THE ARGUMENT.

This treatise opens with a description of the bones of the head,

which, although in most respects pretty accurate, is remarkable for
containing an account of particular configurations of the cranium,
and of certain varieties in the arrangement of the sutures, which it
has puzzled modern authorities in anatomy to explain, otherwise
than upon the supposition that the writer must have been but
imperfectly acquainted with the subject. But as the work otherwise
bears evidence that our author must have examined the bones of
the head very carefully, and moreover, as in all his works he displays
a wonderfully minute acquaintance with osteology, (to say nothing of
the historical tradition, mentioned by Pausanias, that he was
possessed of a skeleton, which at his death he bequeathed to the
Temple of Apollo, at Delphi,) it seems incredible that he should have
committed most glaring blunders in describing the prominent
features of a part to which it is clear that he had paid very great
attention. Moreover, the reputation of Hippocrates for accuracy stood
so high, that an eminent authority does not hesitate to declare of
him, that he was a man who knew not how to deceive or be
deceived.[744] An easy way of getting rid of the difficulty would no
doubt be, to adopt the conjecture advanced by Scaliger,[745] and in
part approved of by Riolanus,[746] that the treatise had suffered
much in early times, from the interpolations of ignorant transcribers;
or to hold, with M. Malgaigne, that the whole work is to be
condemned as spurious. But it would be a dangerous practice in
ancient criticism, to reject as spurious a work which has such
unexceptionable evidence in its favor, although it may contain matter
which appears to us derogatory to the reputation of its author, and it
will be admitted, by any competent judge who examines the
arguments by Scaliger, that the proofs which he brings forward of
great interpolations in this treatise, are generally of a very fanciful
nature.
On a point so obscure, and which has puzzled so many eminent
scholars, it is to be feared that I shall not be able to throw much
additional light, but as, consistently with my general plan, I cannot
well avoid stating some opinion on the question I shall endeavor to
elucidate it in so far by giving in the first place a brief sketch of the
information supplied by all the other ancient authorities who have
touched upon this subject. I shall begin, then, with Aristotle, the
contemporary of our author, who, in his work “On the History of
Animals,” gives the following very inaccurate description of the
sutures of the human skull: “The female cranium has one circular
suture, but men generally three, which unite in one point. But a
male skull has been seen not having a suture.”[747] Celsus describes
the sutures in the following terms: “Ex ceteris, quo suturæ pauciores
sunt, eo capitis valetudo commodior est. Neque enim certus eorum
numerus est, sicut ne locus quidem. Ferè tamen duæ, super aures,
tempora a superiori parte discernunt; tertia ad aures, occipitium a
summo capite deducit; quarta, ab eodem vertice per medium caput
ad frontem procedit; eaque modo sub imo capillo desinit, modo
frontem ipsam secans inter supercilia finitur.” (viii., 1.) “Nam neque
utique certa sedes, supra posui, suturarum est.” (viii., 4.) Pliny gives
the following description of the head, which it is impossible not to
recognize as having been borrowed from our author: “Vertices bini
hominum tantum aliquibus. Capitis ossa plana, tenuia, sine medullis,
serratis pectinatim structa compagibus.”[748] Of Ruffus Ephesius I
may just mention, that his descriptions of the human body are in
general remarkable for their correctness, which is not to be
wondered at, as he would appear to have followed, in general,
Erasistratus and the other authorities belonging to the great
Alexandrian period in anatomy; and that he has described very
accurately all the sutures of the human cranium, but says not a word
of the different configurations of the head, as here given by our
author.[749] We now come to Galen, who gives a very lengthy
description of the various forms of the head, in nearly the same
terms as our author, and after alluding to the uses of the sutures,
the principal of which he holds to be to permit transpiration from the
brain, he proceeds thus to describe the distribution of the sutures:
“That there is one which runs straight along the middle of the head,
(the sagittal?) and two transverse, (the coronal and lambdoid?) has
been stated previously, and need not require many words in this
place. For, the head being like an oblong sphere, one was justly
made to extend straight through its middle from behind forwards,
and two transverse sutures meet it, and the form of the three
sutures is like the letter H. For the whole head being more elongated
in this case than usual, and, as it were, compressed towards the
ears, it was equitable that the number of the sutures should be
unequal as to length and breadth, otherwise Nature would
undeservedly have been named just, by Hippocrates, in thus giving
equal gifts to the unequal. But it is not the case; for being most just,
she formed the strongest suture which extends along the length of
the head single, being thus proportionate to the width of the parts
on both sides of it; namely, on the right and on the left; but she
formed the transverse double in number, the one behind, as formerly
said, called the lambdoid, and the other before, called the coronal,
so that the bone of the head between these two sutures might be
equal to those in the middle, on each side (the parietal bones?). The
sutures of the head, in that configuration which is acuminated,[750]
furnish a very great example of the justness of Nature. For there are
three principal figures of the head: the one entirely opposed to the
natural configuration already described, when the head loses both its
protuberances, that behind and the other before, and is equal on all
hands, and like a true sphere; and two others, the one form having
no protuberance in front, and the other none in the occiput. The
sutures of the spherical head are like the letter χ, two only in
number, and intersecting one another; the one extending transverse
from the one ear to the other, and the other extending straight
through the middle of the vertex to the middle of the forehead. For,
as when one part of the head is excessive, being longer than the
other, it was just that the longer form should have more sutures, so,
when both are alike, Nature bestowed an equal number on both. But
in the head which wants the protuberance at the occiput, the
straight and the coronal sutures remain, but the lambdoid is wanting
(it being near to the protuberance that is wanting), so that the figure
of the two resembles the letter T; as also when the protuberance of
the head in front is wanting, the coronal at the same time is
wanting, but there remains the one running lengthways and joining
the lambdoid, and this form of construction is made to resemble the
letter T. A fourth species of acuminated (sugar-loaf) head might be
imagined, but which does not occur, with the head more prominent
at the two ears than in front and behind.” He goes on to state the
reasons why there is no such construction of the head as this, and
concludes as follows: “Wherefore Hippocrates described four
configurations, and the sutures of each, in the manner we have now
said that they exist, being justly distributed to each configuration by
Nature as to position and number.”[751] The description of the bones
and sutures of the head, given in the Latin work “De Ossibus,”
generally attributed to Galen, is to the same effect. The same
number of distinct configurations of the head, and the same
characters as regards the sutures, is also given by Avicenna, who
professedly copies from Galen. (I., i., 5, 3.)
When examined together, these descriptions certainly must be
admitted to have the appearance of being all derived from one
original, namely, from our author, in this place; and taken literally,
there can be no doubt that their meaning amounts to this: that the
number of the sutures varies with the form of the head; that when
there are protuberances both before and behind, the head in its
upper part has two transverse sutures, namely, the coronal and the
lambdoid, and one longitudinal, namely, the sagittal; that if the
anterior protuberance be wanting, the coronal is wanting, and, if the
posterior, the lambdoid. Now I need scarcely remark, that modern
anatomists do not recognize such varieties in the configuration of
the head nor in the numbers of the sutures, and that it is very rare
indeed for either the coronal or the lambdoid suture to be found
wanting. To all appearance, then, Galen was mistaken, and it only
appears remarkable that, with all his knowledge of anatomy,
theoretical and practical, and considering the opportunities which he
must have possessed of examining human skeletons in Alexandria,
he should have failed to observe and describe the bones of the
cranium for himself.
Before stating my own conjectures on this question, it may be
interesting to examine the solution of it attempted by authorities
who lived about the period when the original study of human
anatomy was revived in modern times. In the first place, then, I may
mention that Ambrose Paré, who, I need scarcely say, was
possessed of no mean talent for original observation, in treating of
fractures of the head, adopts exactly the description given by
Hippocrates; thus he describes “the bunches of the head” in nearly
the same terms as our author, and adds, that such “bunches change
the figure and site of the sutures,” and that “there be some skulls
that want the foremost suture, and other some the hind, and
sometimes none of the true sutures, but only the false, or spurious,
remain.”[752] Nay, it. cannot but appear remarkable, that Vesalius,
the great antagonist of Galen and of the ancient authorities in
general, in the present instance does not venture to call in question
their opinion, but gives a description of the different forms of the
head, and the varieties of the sutures, which scarcely at all differs
from that given by Hippocrates.[753] It is singular, also, that certain
other authorities, who were much more disposed to show a leaning
to antiquity, such as Columbus, Eustachius, Fallopius, and Riolanus,
should, in the present instance, have manifested a more
independent spirit in challenging the authority of Hippocrates,
though, at the same time, they show a disposition to find out some
mode of bringing him clear off. Thus, for example, Riolanus is
compelled to admit that there is no such variety in the forms and
numbers of the sutures as Hippocrates describes; but he attempts to
free him from error, by suggesting that the cases in which
Hippocrates found them wanting must have been those of old men.
[754] He also quotes some very extraordinary instances, in which
something approaching the varieties described by our author had
been remarked.[755] Fallopius does not hesitate, in his great
anatomical work, to express the surprise he felt that all the
authorities should have assented to the descriptions of the
protuberances and sutures of the head given by Hippocrates; for
that he, after having examined large heaps of crania in the Musea of
Ferrara and Florence, had not found that they agreed with the
descriptions given by Hippocrates; that he had seen crania without a
suture, and yet not wanting in the protuberances; and in like
manner, that he had seen the coronal suture obliterated, and yet the
skull possessed its anterior prominence, and the lambdoid wanting,
although the posterior protuberance was as usual. Altogether, then,
in this work he modestly ventures to impugn the authority of
Hippocrates.[756] In his work entitled “Expositio in Librum Galeni de
Ossibus,” he adopts the same views, and there declares that he had
never seen the sutures obliterated except from old age. But, in his
work entitled “Expositio in Lib. Hippocrat. de Vulneribus Capitis,” he
gives two suppositions, which he had devised in order to defend the
authority of Hippocrates: first, that Hippocrates did not give these
varieties of form as real, but as hypothetical; and second, that he
merely described them as being the vulgar opinion, without pledging
himself to the correctness of the description. These, as far as I am
aware, are the only defences which have ever been set up for our
author in this matter, and it must be admitted that they are not very
satisfactory. I shall now present the reader with the conjectural
explanation which has occurred to myself. I have imagined that what
Hippocrates meant was to express himself to the following effect:
when the forehead is remarkably prominent, and, at the same time,
there is a great depression behind, the cranium, if looked upon from
above, will show the coronal suture running across the fore part of
the head, and the sagittal through its middle, while the lambdoid will
be inconspicuous, from being below the level of the coronal. The two
together, then, would form some resemblance to the letter T. When,
on the other hand, the forehead is low, that is to say, wants its
normal development, and the occiput is unusually prominent, the
lambdoid suture joins the sagittal, so as to present some appearance
of the same letter reversed. But in a square-built head, where the
frontal and occipital regions have protuberances equally developed,
the coronal and lambdoid sutures run nearly parallel to one another,
and are joined in the middle by the sagittal, in which case the three
sutures may be imagined to present some resemblance to the Greek
letter Η. When there is no protuberance either before or behind, and
the sagittal suture passes through the middle of the bone down to
the nasal process, the coronal suture intersects it, so as to give them
something like the shape of the Greek letter χ.[757] I offer this
explanation, however, merely as a conjecture, and wish the reader
to judge of it accordingly.
I now proceed to give an analysis of the contents of this treatise,
and to attempt to form a correct estimate of their value.
Injuries of the cranial bones are divided by our author into five
orders, as follows: 1, simple fractures, or fissures of various kinds
and sizes (§ 4); 2, contusion, without fracture or depression (§ 5); 3,
fractures attended with depression (§ 6); 4, the hedra, that is to say,
the indentation or cut in the outer table of the bone, and not
necessarily attended either with fracture or contusion (§ 7); 5, the
counter-fissure, or fracture par contre-coup fracture and the severe
contusion, require the operation of trepanning; whereas neither the
hedra (or simple cut) nor the depressed fracture require it, and the
counter-fissure does not admit it, owing to the obscurity of the
symptoms with which it is attended (§ 9).
In the first place, the surgeon is to ascertain the nature and
situation of the wound, by a careful investigation of all the
circumstances of the case, but so as to avoid the use of the sound, if
possible (§§ 9, 10).
Next are described the various kind of injury which the different
sorts of weapons are most likely to inflict, and from the
consideration of them the surgeon is to form an estimate of the
probable nature of the accident (§ 11).
 The characters of the hedra, or superficial injury of the cranium,
and the difficulty of forming a correct estimate of it, when
complicated by the presence of a suture, are strongly insisted upon
(§ 12).
The principles upon which the treatment of injuries situated in
different parts of the head should be treated, are carefully defined
and stated. Great, and as now would be thought, superfluous
directions are given, for ascertaining whether or not a fissure exists
in the bone. The treatment, as far as applications go, is to be mild
and desiccant. When a fracture cannot be made to disappear by
scraping, the trepan is to be applied (§§ 13, 14).
The dangers which the bone incurs of becoming affected from
the soft parts, are strongly insisted upon, and applications of a
drying nature are prescribed (§ 15).
The condition of a piece of bone which is going to exfoliate is
correctly and strikingly described (§ 16).
The treatment of depression is laid down, and the danger of
applying the trepan in this case is strongly insisted upon (§ 17).
The peculiarities in the case of children are pointed out. Under
certain circumstances, when there is contusion combined with the
fracture, he admits of perforating the skull with a small trepan (§
18).
When, after a severe injury, symptoms of irritation and
inflammation appear to be coming on, the surgeon is to lose no time
in proceeding to the operation. Some correct observations are made
on the consequences of injuries of the head on other parts of the
body (§ 19).
The treatment of erysipelatous inflammation is distinctly laid
down (§20).
The operation of trepanning the skull is circumstantially
described, and an interesting description is given of a mode of doing
the operation peculiar to our author[758] (§ 21).
 This, then, as far as I know, is the first exposition ever made of a
highly important subject in surgery, upon which professional men are
still greatly divided in opinion. I cannot, then, resist the temptation
to offer some remarks on the views of practice here recommended,
and to institute a comparison between them and certain methods of
treatment which have been in vogue of late years.
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:
—“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.
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.
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]
7. When a hedra, or dint of a weapon, takes place in a bone,
there may be a fracture combined with it; and provided there be a
fracture, contusion must necessarily be joined, to a greater or less
extent, in the seat of the dint and fracture, and in the bone which
comprehends them.[789] This is the fourth mode. And there may be
a hedra, or indentation of the bone, along with contusion of the
surrounding bone, but without any fracture either in the hedra or in
the contusion inflicted by the weapon. But the indentation of a
weapon takes place in a bone, and is called hedra, when the bone
remaining in its natural state, the weapon which struck against the
bone leaves its impression on the part which it struck. In each of
these modes there are many varieties, with regard to the contusion
and fracture, if both these be combined with the hedra, or if
contusion alone, as it has been already stated that there are many
varieties of contusion and fracture. And the hedra, or dint, of itself
may be longer and shorter, crooked, straight, and circular; and there
are many varieties of this mode, according to the shape of the
weapon; and they may be more or less deep, and narrower or
broader, and extremely broad. When a part is cleft, the cleft or notch
which occurs in the bone, to whatever length or breadth, is a hedra,
if the other bones comprehending the cleft remain in their natural
position, and be not driven inwards; for in this case it would be a
depression, and no longer a hedra.[790]
8. A bone may be injured in a different part of the head from that
on which the person has received the wound, and the bone has
been laid bare. This is the fifth mode. And for this misfortune, when
it occurs, there is no remedy; for when this mischief takes place,
there is no means of ascertaining by any examination whether or not
it has occurred, or on what part of the head.[791]
9. Of these modes of fracture, the following require trepanning:
the contusion, whether the bone be laid bare or not; and the fissure,
whether apparent or not. And if, when an indentation (hedra) by a
weapon takes place in a bone it be attended with fracture and
contusion, and even if contusion alone, without fracture, be
combined with the indentation, it requires trepanning. A bone
depressed from its natural position rarely requires trepanning; and
those which are most pressed and broken require trepanning the
least; neither does an indentation (hedra) without fracture and
contusion require trepanning; nor does a notch, provided it is large
and wide; for a notch and a hedra are the same.[792]
10. In the first place, one must examine the wounded person, in
what part of the head the wound is situated, whether in the stronger
or weaker parts; and ascertain respecting the hairs about the
wound, whether they have been cut off by the instrument, and have
gone into the wound; and if so, one should declare that the bone
runs the risk of being denuded of flesh, and of having sustained
some injury from the weapon. These things one should say from a
distant inspection, and before laying a hand on the man;[793] but on
a close examination one should endeavor to ascertain clearly
whether the bone be denuded of flesh or not; and if the denuded
bone be visible to the eyes, this will be enough; but otherwise an
examination must be made with the sound. And if you find the bone
denuded of the flesh, and not safe from the wound, you must first
ascertain the state of the bone, and the extent of the mischief, and
what assistance it stands in need of. One should also inquire of the
wounded person how and in what way he sustained the injury; and
if it be not apparent whether the bone has sustained an injury or
not, it will be still more necessary, provided the bone be denuded, to
make inquiry how the wound occurred, and in what manner; for
when contusions and fractures exist in the bone, but are not
apparent, we must ascertain, in the first place from the patient’s
answers, whether or not the bone has sustained any such injuries,
and then find out the nature of the case by word and deed, with the
exception of sounding. For sounding does not discover to us whether
the bone has sustained any of these injuries or not; but sounding
discovers to us an indentation inflicted by a weapon, and whether a
bone be depressed from its natural position, and whether the bone
be strongly fractured; all which may also be ascertained visibly with
the eyes.[794]
11. And a bone sustains fractures, either so fine as to escape the
sight, or such as are apparent, and contusions which are not
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