We find cases on record in which it is evident that traumatic encephalitis was mistaken for compression, and the skull trephined; and in some such instances good effects have followed, evidently from the local bleeding, which, in several of these cases, was considerable; or, perhaps, from the preliminary incising of the pericranium, which we know has, in some cases, succeeded of itself in removing symptoms analogous to those caused by on the right side, then on the left side of the head, afterwards upon the forehead, and lastly upon the occiput, and so all round until you meet with the seat of the disorder." Even in recent times the same practice has been recommended by Benjamin Bell, who says we must " form the first perforation in the most inferior part of the cranium in which it can with any propriety be made, and proceed to perforate every accessible part of the skull till the cause of the compression is discovered." Dease's third case, and that of M.
A. Farnham in Guthrie (p. 243 of the last edition), are good and parallel illustrations of this. In both there were signs of pressure on the brain. In Dease's case there were all the signs of pus having formed. In Guthrie's the paralysis, were the orthodox symptoms of pressure. Both were trephined, and in both the dura mater and bone were found perfectly sound. Both were immediately relieved of their symptoms and recovered, although one nearly "died of the doctor." IN.ITKIKS OF Blood rapidly rli'used may often passes on" as the effusion is absorbed; or mere congestion, the result of injury, i rise to th symptoms, and be allayed by deyet, it' we trephine early, we may have only such tions to contend with.
1 1 the bone be very deeply depressed on the brain, and the patient be comatose, with stertorous breathing, slow pulse, and dilated pupil, then it may be admissible piacthe elevator cautiously, with, or without the of Keys' saw; but in all eases in whieh the bone is not very deeply depressed, and in which tb symptoms are not very decidedly marked, nor have continued tor a considerable time, I do not believe any interference should be attempted. It is too much the custom, I think, to deny or overlook the danger which arises from the operation itself. This is no place to impure what is the source of this dai her it he the admission of atmospheric air to the as supposed by Larivy and Stromeyer, or the rniewrd irritation and injury ot'the brain cover; Bothers say, fr-.m pus poisoning; but the tthe most serious, and at times fatal symptoms, have folio' -cs in which, contrary lit the hone were found nii<! in th.-ojhrrtli,- vessels of the diploe "bleeding.
" probably account for the result. These were both cases of secondary in here with reference to the point hinted at hi the ir.n of trephining needs lit 1 1. as it b one of the beft recognized surgical facts. Take such n tromeyer, who tells us that during the three yean be of the skull, followed at a late date by compression, is perhaps the most hopeless of all the circumstances in which the trephine can be used, yet it seems that in which it is most properly and incontestably employed. Rigors followed by vomiting, a rapid pulse, stupor, delirium, and palsy, usher in a condition of things which, except in rare cases, is fatal. The longer the time which intervenes before the appearance of such symptoms, the more deadly does their indication appear to It is well known, that in the majority of these tended the hospitals of Vienna, London, and Paris, he had not met with a single successful case, while many severe injuries recovered which were left alone.
In the New York hospital only one-fourth of their cases recovered, t e., eleven cases out of forty-five. In ten of these the operation was prophylactic, and in thirty-two therapeutic; three of the former and eight of the latter recovered. In India I find a record of four cases of trephining for symptoms setting in late, and all ended fatally. In the Glasgow hospital register I find no record of a recovery after trephining. In University College hospital Mr. Erichson speaks of four cases of recovery in thirteen operated on, and in the Paris hospitals Nelaton tells that in fifteen years all their operations of this kind for traumatic effusion have ended fatally. Mr. Guthrie thinks the danger greater when the operation is performed late.