THi: II I. Ah. to cur the 1 pain which so often remains t at tin- plaee of injury. ther surgeons, again, discarding and condemning all this, say we should trephine only when there is depression; but the amount of depression which demands it, each interprets according to his None knows so well as the army surgeon how very considerable a depression may exist, especially tl of the head, without any injury to the brain: nor innumerable are the cases in which great dehas been present, without causing harm at any pient period of the patient's life. A musket ball being the wounding cause, would appear to some a sufficient reason why the trephine should be applied, however slight may be the lesion.
"We should Always trephine," says Quesney, " in wounds of the head caused by fire-arms, although the skull be not All the best practitioners," says Pott, in acknowledging the necessity of perforating the skull in the case of a severe stroke made L,om-shot, upon tin- appearance of any threatensymptom, even though the bone should not be brokm: and V.TV Lr<>d practice it is." Boyer and. epially uru'eiit when a ball has caused the injury. However, "the experience of war," to which Quesney in confirmation of his opinion, now-adays c'-mplctely condemns the practice, whatever it may Further, '; symptoms of compression " setting in early id down l,y Mthers as urgently demanding: the n-mnval of the < injury," says.lolm uires o; 'inpression of the brain. which may arise eitl,'-r fr<.abated blood, or from WAIi. depressed bone, or matter generated within the skull." But, unfortunately, we can seldom diagnose the existence of compression with any amount of certainty, when it sets in early, and experience teaches us that each and all of those signs which are said to indicate it may, under appropriate treatment, pass away without interference; especially when these symptoms appear early, and often, also, when they set in late.
Compression, too, when it appears at a late date, if it arise, as it generally does, from the presence of pus, is well known to be seldom relieved by trephining. Dease first showed how it was that the matter was commonly deeply placed or diffused in such cases; and the instances in which it has been found on the surface, or evacuable by such a bold manoeuvre as the well-known thrust of Dupuytren, are exceedingly rare. Some authors, again, would have us trephine only when the symptoms of compression are severe, go on increasing in severity, and have continued for some time; yet, even under such circumstances, " recovery not seldom disappoints our fears, and mortifies us by our But, finally, it is to those surgeons who instruct us to operate when certain pathological conditions exist, which they carefully define, but which experience, unfortunately, tells us do not often manifest themselves by any recognizable signs, that we are chiefly indebted for See, especially, as good instances of this, Quesney's first and second observations.
In the first, the stupor and delirium lasted three months, and in the other, it had continued also for a lengthened time. Stromeyer, by antiphlogistic remedies alone, saved several in which the " stupor had lasted for weeks together." OF THE ful directions to assist us in cases of difficulty. AY hat good can it do to say, you must trephine when the internal table is splintered more extensively than the nial, when eii'usion has taken on the "brain, and so on, when we have often no means of knowing when these conditions exist, or whrn we are fully aware that they have, each and all. l>een present, and that to a very considerable extent, without any of their Appropriate siirns beinir manit'est?
Hut to refer more particularly to those cases which fall to the charge of the military surgeon. There are three classes to which the trephine is still occasionally applied: 1st, fracture with depression, before symptoms have appeared; 2nd, fracture with depression, attended immediately with signs said to indicate compression; and 3rd, fracture, with or without depression, followed at a late period by symptoms evidencing compression. It is with reference to the first class of cases that "the experience of war" is most useful, and most decided. Tin-re are. I few surgeons of experience in the army now-a-days who approve of "preventive It may be said in our time to be a practice That blood may be effused," says Guthrie, " and mattrr may be formed is indisputable, evrn under tin- im-t a.-tivr tn-.itincni; l.iit that inn by the trephine will anticipate and prevent these evils, cannot be conceded in 'sent state of our knowledge: and tli.rule of practice is at present decided, that no such operation should done until inptoms distinctly nt -hat compression or irritation,,r tin- brain has taken place.
It to argued that, when these symptoms do occur, it will be too late to have recourse to the operation with success; this may be true, as such cases most always be very dangerou*. hut it does not follow, and it never hat been, nor, indeed, can it be shown, that the same mischief would not havt> taken place if the operation had been performed earl SUHCJKKV <>F T1IK (KIM KAN WAR. of the past a practice to be pointed at as a milestone which we have left behind. A very large number of instances fell under my own notice in the East, in which, by the use of evacuants and quiet, and the absence of all operative interference, a perfect and uninterrupted recovery followed these injuries, even when the bone was very extensively depressed.