INJURIES. 



honour by the candour with which he acknewlcJgcJ his 

 having fallen into an error of this kind. 



We (hall conclude this fubjcil with a few obfervations on 

 the treatment of fractures of the ilciill. For the rehef of 

 thefe cafes, there cannot be a doubt that the ufefalnefs of 

 trepanning has been nioft unreafonably magnified. Tiie 

 necefiity of only pradlifing this operation wlien it is abfo- 

 liitely requifue, mull be manifcll to every one, who reflects, 

 tliat cutting auay a portion of the (kull is a proceeding by 

 no means free from the hazard of very dangerous confc- 

 quenccs. We have alfo the tclliniony of fcvL-ral eminent 

 furgic;J writers, tliat it is an operation, generally fpeaking, 

 attended with remarkable ill fuccefs. It is not our inten- 

 tion, however, to endeavour to inllnuate, that the fatal 

 terminations are not chiefly afcribable to the ferious mifchief 

 which commonly exifts when tlie operation is performed. 

 Be this as it may, we cannot help looking upon trepanning 

 ts a thing, to which reconrfe (hould never be had without 

 flrong and urgent reafon. Default, the moll eminent of the 

 modern French furgeons, entirely abandoned tlie operation 

 in the latter years of his praftice, as he found conliderable 

 fuccefs arife from the emplnyment of evacuations. " Cell 

 une obfervation fort ancienne, que le pen de fucces de I'opc- 

 ration du trepan pratiquee a I'llotel-Dieu de Paris ; foit, 

 que I'air des falles, vicie pir le grand nombre d'individus, 

 qui s'y trouvent raflembles, ou par I'humiditc dont le voi- 

 fmaore de la riviere le charge conftamment, exerce fur la 

 place, que fucccde I'oplration, ou far les membranes du 

 cerveau mifes a nu, une influence dclctere, foit que ce fait 

 conilaiiT depende d'une autre caule ignoree. Pope-ration du 

 trepan eft prefque toujours fuivie de la niort des indivi- 

 dus." Richerand, Nofographie Chirurgicale, torn. ii. p. 266. 

 Edit. 2. 



That the operation of trepanning is itfelf not exempt 

 from ferious danger we moil firmly believe. Wc have fcen 

 it prove fatal, when performed with a view of relieving a 

 Tiolent inveterate head-ache. Yet we cannot bring our mmd 

 to beheve, that Default was right in rejecting the operation 

 altogether. There certainly are ca'es in whicli it may be 

 the means of prefer\'atinn as well as others, in vvliich it may 

 exafperate circumftances and render them fatal. 



We have noticed that, in fraclures of the Ikull, the ope- 

 ration of trepanning was advifed by Pott, as a preventive 

 of ill confequences. It gives us pleafure to llate, that tiiis 

 practice is now never adopted by the moft eminent furgeons 

 in this country-, great as tlicir veneration is for fo diltin- 

 guiflied. an authority. Many modern writers of the highcll 

 reputation have forcibly remonllrated againll the method, 

 as M. Default, of Paris '; Mr. Deafe, of Dublin ; Mr. John 

 Bell, of Edinburgh ; and Mr. Abernethy, of London. 



The reader cannot be furprifed, that fractures without 

 depreffion are not, abllraCtedly confidered, a jull caule for 

 trepanning, when he is informed, that the ikull is often 

 broken and deprelTed, and yet the fymptoms may not be 

 fuch as to demand the operation, and the patient has the 

 bed chance of recovery when it is not performed. The 

 more the prefent fubjeit is lludied, the greater will be the 

 conviction, that there is only one genuine reafon for tre- 

 panning, and that is, when fymptoms of a dangercnis 

 degree of preffure on the brain exilt, v.-hich fymptoms are 

 enumerated under the head of ExTii-\v.v.s.\Tio>i. When 

 they prevail, the operation is to be done, whether the (liull 

 is broken or not ; whether it be depreded or retain its pro- 

 per level. 



Mr. Abernethy has related feveral cafes of fradture of 

 the cranium with deprcflion, which terminated favourably, 

 although no operation was performed. This judicious fur- 



VoL. XIX. 



geon thinks, that thefe cafes, as well as a grcidt many others' 

 on record, prove, that a flight degree of prelfure docs not 

 derange the funftions of the brain for a limited time after 

 its application ; and all thofe patients whom he had an op- 

 portunity of knowing for any length of time after the acci- 

 dent, continued as well as if nothing of the kind had hap- 

 pened to them. In Mr. Hill's Cafes in Surgery, two 

 inilances of this fort are related, and Mr. Hill knew both 

 tlie patients for many years afterwards ; yet no inconveni- 

 ence arofe. Indeed, it is not eafy to conceive that the prel- 

 fure which caukil no ill effvfts at a time when the contents 

 of the cranium filled its cavity entirely, (hould afterwards 

 prove injurious when they have adapted themfelves to its 

 altered lize and (hape. Severe illuefs, it nuill be confelfed, 

 does often intervene between the receipt of the injury and 

 the time of recovery ; and many furgeons might be in- 

 clined to attribute this to the preifure on the brain ; but it 

 occurs quite as fbrmidably when the depreffed portion is 

 elevated. If a furgeon, prcpoffefled with the opinion, tliat 

 elevation of the bone is neceffary iu every inllance of frac- 

 ture of the fliuU witii depreffion, Ihould have adlcd upon 

 this opinion in feveral of the cafes which Mr. Abernethy 

 has related, and afterwards have employed proper evacua- 

 tions, the patients would probably liave Had no fatal fymp- 

 toms, and the recoveries would naturally have been imputed 

 to the particular mode of treatment ; yet thefe cafes ended 

 well without any operation. 



It cannot be too often repeated, that the neeeffity of 

 trepanning depends entirely on the urgency of the fymp- 

 toms, which are known to proceed from the exiilence of 

 preffure on the brain. (See Extravasatio.v.) To tre- 

 pan the flvull merely becaufe it is broken, is as abfurd as ta 

 cut the arm becaufe it is fraftured : it is only adding one 

 fpecies of violence to another. Wc have feen that, even 

 when the fraCture is depreifed, it does not neceflarily follow 

 that the operation is proper : in fact, it is always improper, 

 unlefs there are evident figns that the degree of preffure, 

 thus produced, is the caufe of exiiling dangerous fymp- 

 toms. 



If, then, fraftures of the cranium with deprcflTion do not 

 invariably require trepanning, it may readily be conceived, 

 that the operation mull be ftill lei's frequently neceflary 

 when the fradture is undcprcfled. In fuch cafe, indeed, 

 the fradture itfelf can never demand this proceedmg. But, 

 neverthelefs, it may be right and indifpenfable on other ac- 

 counts, fince the brain may at the fame time be dangeroully 

 compreffed by an extravafation of blood, or, in the conrfc 

 of the diforder, by matter formed under the Ikull in con- 

 fequenee of inflammation. However, it fliould be wcU 

 underltood, that the uiflammation and fuppuration of the 

 parts beneath the Ikull, which Mr. Pott was fo anxious to 

 prevent by trepanning early, do not arife from the occurrence 

 of a breach in the cranium, but are chiefly, if not altogether, 

 the confequences of the fame violence, which was the occa- 

 fion of the fraCture. Hence, it is obvious, that removing 

 a portion of the bone cannot have the leait tendency to pre- 

 vent the inflammation and fuppuration, wliicli mult ine\ita- 

 bly refult from the external violence that was firit applied 

 to tlie head ; but, on the contrary, fuch a removal being «n 

 additional violence, mull rather have the efl'ect of increafmg 

 the unavoidable inflammatory mifchief. 



A fracture of the ftuU, unattended with urgent fymii- 

 toms, and noi brought into the furgcon's view by any acci- 

 dental wound of the integuments, often remains for ever 

 undifcovered and unknown ; and as no benefit could arile 

 from laying it hare by an ineifion, fncli practice Ihould never 

 be adopted. The practitioner ought only to i*inkc hVinfelf 



