uf this <piestinn from an examination 1C writings of our great masters, the conclusion ii presents itself' is. that as the symptoms calling he use of the trephine have been so variously inter. men of experience; that as the operation has D as it has succeeded in removing the dangers apprehended; that as the which has occasionally followed is ascribable, in many cases, to Other COncum nt eireiinistaiuvs, and not t< the removal ol' the bone: and finally, that as the operation, per 86, is not devoid we should never have recourse to the trephine, unless the indications for its use are WAR. decided, have been present for some considerable time, and have not been assuaged by other remedial measures.
Further, I am disposed, not only from reading, but irom the observation of not a few cases which fell under my notice during the late war, to conclude, regarding the cases and symptoms which demand operation, that primarily, operative interference (under which term is included the use of the trephine, saw, or elevator) in gun-shot wounds of the head, should never be had recourse to, except (1) in cases of fracture witli great depression cases in which the bone is forced deeply into the brain, especially if it is turned so that a point or an edge is driven into the cerebral mass; or (2) unless we clearly make out the impaction of spiculae, balls, or other foreign bodies in the brain, which cannot be removed through the wound by means of the forceps: that secondarily, the cases which call for operation are (1) those in which a foreign body is at this period discovered irritating the brain, and which cannot be extracted without a piece of the bone being removed; or (2) those in which signs of compression set in after a well-marked rigor, continue to increase in intensity notwithstanding treatment, and have lasted for some time.
In the treatment of gun-shot operative proceedings form the least important items, as they can commonly be avoided if the rest of the management be judicious, and their success will chiefly depend on a careful attention to less imposing, but more important measures., In their examination the ringer should alone be employed, and that even with much caution. They should not be enlarged, unless a more important object be held 8 oi Tin: m:\i'. in view than to clear up doubtful points of diagnosis. It' the bone be s> lively destroyed and depressed! v int Tterence, it will make itself suffiily evident without its beinp: necessary to incise the tin- purpose of making the distinction. Stror litly recommends the application of a piece of wet linen t< the wound, whieh, as it adheres to the scalp, the air.