Kemarkable exceptions tthis graduating scale of >. however, occur. There are, at the same time, other cireumstane-s ies the seat and nature of the injury which influence the result. The age of the patient is, perhaps, the most important of these. With children and young persons, the same gravity by no means attaches to tinprognosis of head injuries, as to similar accidents to tin- old. Mr. (inthrie has well observed, that in the accounts of wonderful escapes and successful operations on the head, the subjects have been, in general, below puberty. The temperament of the patient, his excitability, his social condition, as rise to more or less anxiety regarding the result of his case the means there are of carrying out his treatment as to.i.-'lation.&c. tin- place where he is treated, whether in the hospital of a populous city, when the results of such cases are usually so fatal, or in the country, where so much more can be accomplished, all these are imin.L: an opinion regarding injuries of the wounds of the head, chiefly compound, enable IH to ascertain, with tolerable p it of injury which has been inflicted; and it' it louirht necessary to employ any means to el 'ssed bone, we can do so don than SI RGERY OF THE (' IMM KAN if the scalp were unhurt; as, if it be true what some of our best surgeons tell us, that the danger of inflammation in the membranes is increased by opening the integuments, then this source of danger cannot be charged to Such facilities should not, however, make us less careful in our proceedings.
As to the use of the trephine the cases, and time for its application less difference of opinion, I believe, exists among the experienced army surgeons than among civilians; and I think the decided tendency among them is to endorse the modern " treatment by expectancy," and to avoid operation, except in rarecases. In this, I believe, they judge wisely; for, when we examine the question carefully, we find that there is not one single indication for having recourse to operation, which cannot, by the adduction of pertinent cases, be shown to be often fallacious; while, if we turn to authorities for advice, we find that not a great name can be ranged on one side, which cannot be balanced by as illustrious on the other.
Simple contusion, without fracture or depression, caused the old surgeons to " set on the large crown " of a trephine, in order to prevent future danger. Fracture, although not accompanied by depression, or any other untoward symptom, called for the trephine in the practice of the Pott school;f while many, even now, would operate * This source of danger is particularly dwelt upon by Stromeyer, Larrey, and Dupuytren. t This most false doctrine was that also taught by the Academy of Surgery and the leading men in France, till, by the able writings and practice of Bichat and Desault, it was in a great measure rejected; however, it is from the writings of M. Malgaigne, more perhaps than from those of any other, that this question has received its true interpretation.