Decision making in head injury management in the Edwin Smith Papyrus.

The Edwin Smith Papyrus (circa 1650-1550 BC) is a didactic trauma treatise of major interest to neurosurgery, as it deals primarily with cranial and spine injuries. Information regarding the patient's condition is conveyed in the papyrus with sufficient clarity to allow a clinical assessment of each injury. The ancient Egyptian physician/teacher lists the key diagnostic elements in each case, and then pronounces his opinion of the treatment potential in one of three verdicts: 1) "a medical condition I can treat;" 2) "a medical condition I can contend with;" or 3) "a medical condition you will not be able to treat." The structural organization of the text according to regional injuries of increasing severity permits analysis of sequential cases, and makes it possible to determine which clinical features led the ancient Egyptian physician to give the first or second verdict in the less severe injuries, but the third in the worst cases. Interestingly, the ancient physicians were not deterred from contending with injuries in the presence of basilar skull fractures, traumatic meningismus, skull perforation without overt neurological deficit, drowsiness, limited facial fractures, or closed head injuries without depressed fragments. Factors identified as determinant for the third verdict in head injuries are depressed skull fragments, dura laceration with exposed brain, infected cranial wounds/tetanus, major craniofacial fractures, deep skull-penetrating stab wounds, and aphasia. This study describes three case sequences of head injuries.