He thinks the sooner it is undertaken, if it is to be had recourse to at all, the better, " believing the violence to be greater whe'n done on parts already in a state of inflammation, than when they are sound." Larrey expresses himself in almost the same words: " We say then that the trepan should be applied when it is decidedly indicated, before the invasion of inflammatory symptoms, which show themselves more or less promptly, according to the idiosyncrasy of the patient, his age, and the cause of the wound; and when it is developed, the operation should be delayed till these symptoms cease. If this second period does not present itself, it is better to abandon the patient, devoted to certain death, than to try a useless remedy which can only hasten his last moments." * The late period at which dangerous symptoms may be set up, the total absence of any irritation caused by foreign bodies impacted in the brain, which is occasionally observed, are well shown in a case related by M.
Manoury in his report on Roux's service during the year 1841. A student, cases the pus is so situated that it cannot be evacuated by the trephine. It is either diffused over the brain, its membranes, or collected in depots deep within its substance, or at parts distant from the seat of injury. In a considerable number of cases, however, it -'iperticially, when its formation has been occasioned ntrated blow like that of a ball, and may be fund collected beneath the place of injury. It is only in these latter instances that any good can be got from the use of the trephine; but such cases are sufficiently numerous in their occurrence, to indicate its employment, in all instances in which distinct signs of purulent collection set in at a late date.
" It is plainly an abscess of the brain," says John Bell, "and as it is an abscess which cannot burst or relieve itself, though the trepan may fail to relieve the patient, yet without that help he will infallibly die." In this is expressed the true reason for its use in these most hopeless cases. It is in fact a last n-soinvc, which we are not justified in refusing to avail ourselves of. Besides this, it is also true. that, in a considerable number of cases in which the pus has not been found beneath the seat of injury, it has been dis. but slightly removed from it, within rain substance so near that very little would ita evacuation: and it is also well known that with suicidal intent, -li-.t l.y tin- m<>utli.
1 " f.>un<l in tluami M-t!"<: not the least sign appeared of irritation, or presence of su<! i t" bodies. WAR. success has followed the bold expedient, first praci by Dupuytren, of plunging a knife into the brain when the abscess was not found on its surface. The case will end fatally to a certainty, if the matter is not evacuated, and in the event of the attempt failing, such a step, if conducted with proper circumspection, will not add to the gravity of the case.
The following case is mentioned, not only because of the late appearance of urgent symptoms, but also because of the position of the abscess found after death, which was situated as above referred to: A private in the 29th was hit by a ball above the eye. The frontal bone was smashed, and the ball was lost apparently in the brain. No head symptoms whatever followed. Some loose pieces of bone were removed, but two parts which were depressed were not interfered with. The antiphlogistic treatment was decidedly maintained. For three weeks no symptoms appeared to create alarm; at the end of that period, however, a good deal of local inflammation was set up, and the depressed portions of bone, being found loose, were removed.
Very little disturbance followed this step, and he was finally discharged, about four months after the receipt of the injury, apparently quite well. A month after dismissal he returned into hospital, complaining of feverishness, headache, and a 1 nirried and excited manner. There was nothing particular found at the seat of injury. The cicatrix was in the same condition as when he left the hospital. The brain-pulse was evident, as it had been since the bone was withdrawn. Coma occurred shortly after his admission, ending in death sixty hours from the first bad symptom. When the head was opened, the hiatus in the bone remained unchanged, only that the edges of the IN.II 1:1 i:s or Tin: BEAD. smoothed and beveled off, and somewliat darker in colnur than the rest of the ealvarium.