NOTE. The following papers were received by the Committee. of Publication as having been read before this Section, and referred, though not mentioned in the Minutes.

Some Points in the Treatment of Hemorrhoids. By WILLIAM R. D. BLACKWOOD, M.D., of Pennsylvania. A Method of Treating Spinal Disease. By E. H. COOVER, M.D., of Pennsylvania. Treatment of Fractures of Long Bones involving Joints. By JAMES S. GREEN, M.D., of New Jersey. A new Appliance for the Treatment of Club-Foot and other Deformities. By GREGORY DOYLE, M.D., of New York.

A PLEA FOR THE PREVENTIVE TREPHINE.

By W. T. BRIGGS, M.D.,

TENNESSEE.

MR. PRESIDENT AND GENTLEMEN:

In obedience to the requirement of the laws of the Association devolving upon the Chairman of each Section the duty of reviewing in the form of an address, such advances and discoveries as may have been made during the past year in the special department over which he was chosen to preside; or to perform the alternative of pronouncing an essay on some topic of large importance and general interest connected with that department, I propose within the limits of the allotted time, to discuss a surgical procedure than which none is older in the history of the science and art of medicine, and on which so much has been said and written, that it may be thought to have become trite, if not threadbare, viz., the preventive trephine. Parenthetically it is proper to remark, that the term trephine will be used in a comprehensive sense. Authors generally draw distinctions between the application of the trephine proper, and the employment of other instruments of the trephine case. It is difficult to appreciate the necessity of considering separately the operations by several instruments, obviously used for the same purpose. The operation, by whatever special instrument effected, is a means to the end, viz., the removal of fragments of the skull; and this paper will designate under the term trephining, any procedure adopted to accomplish that object.

It is hoped to enlist the interest of this body to some degree, notwithstanding the subject has been for so many eras in the history of surgery belabored by such various and contradictory views. The great importance of the proper treatment of injuries of the head, the frequency with which the question of life or death is involved in their consideration, and the formidable mortality attending such casualties, invest the subject with

paramount interest, and have induced me to select it as a theme for this occasion, in preference to others which would have the attractiveness of novelty. My choice was further influenced by strong evidences of a recently awakened interest in the subject both at home and abroad. It is not claiming too much to assert that a revolution of opinion in favor of the trephine is now in progress, and that a larger appreciation of its merits is now obtaining. There can be no doubt but that its field of usefulness is constantly widening, and it is confidently predicted that in the near future the operation will assume and maintain among surgical procedures enjoying full favor of professional esteem the just rank to which it is entitled.

Injuries of the head have engaged the attention and profound study of the most brilliant intellects of the profession in every age. The philosophical dictum of Hippocrates, "Nullium capitis vulnus contemnendum" has been strengthened by the accumulated experience of centuries. The close, compact structure of the bony envelope of the encephalon, its exposure to frequent traumatism by reason of its position, the high grade of sensibility of the brain, its ready susceptibility to the slightest irritation, the formidable and often fatal consequences of lesions of that organ, and the difficulties that intervene to prevent an accurate discrimination of the extent of involvement, all combine to render the subject a most important and interesting one.

That such a chain of circumstances should suffice to have engaged the master minds of the profession in the question of operative interference for the relief of head injuries, is not a matter of astonishment; but it is a grave reproach upon the profession, that with all its boasted advance in the acquisition of surgical knowledge, and in the perfection of surgical skill, it is yet not a whit nearer to the solution of this momentous question than it was many years ago. The most rational treatment of injuries of the head still remains a quæstio vexata.

If we take a rapid review of the past, we will be struck with the mutability of opinion concerning very many of the most important subjects pertaining to medicine and surgery. In every department of medicine we will observe the variable position that certain remedial measures and operative procedures have held in professional estimation at various periods.

Bloodletting, which only a few years since was practised the world over for the alleviation of almost "every ill to which

human flesh is heir," has been the subject of the most complete revolution, and is now so rarely practised in the treatment of disease as to deserve the designation of "one of the lost arts," recently given it by a distinguished member of this body.

The operation of lithotomy, for a long time practised as the only means of removing stone from the bladder, in the early part of its history was eclipsed and almost supplemented by lithotrity, introduced by Civiale. Experience fairly proved the inadequacy of the new method, and after a time the cutting operation regained ascendency. At the present time, lithotomy is again threatened by its old rival in a new guise. Litholopaxy, a new term applied to the crushing process, practised upon principles enunciated and demonstrated by Bigelow, has gained rapidly in favor since its recent introduction, and has already encroached upon fields hitherto appropriated exclusively to lithotomy.

Numerous other examples might be adduced illustrative of this fickleness of sentiment; but none would present a record of greater instability than the operation of trephining.

The voice of authority, the tyranny of fashion, but chiefly the difficulty and doubt that invest the subject, combine to produce this want of unanimity and confusion of ideas.

Recent communications in the Bulletin de la Société d'Anthropologie, by MM. Prunières, Broca, Engelhart, etc., have conclusively proved that the operation of trephining was practised, either as a religious rite or as a surgical measure in prehistoric times.

The earliest authentic information of the trephine, however, is found in the writings of Hippocrates. He and his followers for several centuries, frequently employed it for a variety of causes. In the middle ages, the operation was not only performed by physicians, but also by strolling mountebanks (circulatores) and ignorant artisans, who bored the skull for the most trivial causes, and most generally, strange to say, with perfect safety.

Advocated by Pott, denounced by Desault, having engaged the best intellectual energies of such surgical celebrities as the Bells, Coopers, Hunters, and Quesnay, Abernethy, Dupuytren,' Velpeau, Nélaton, and many others, by some of them approved,

La Trepenation guidée par les Localisations Cérébrales, par le Dr. Juste Lucas Championnière, Paris.