Desault had become extremely disgusted with the results of the operation of the trephine in his hands at the Hôtel Dieu; and, on consideration, although, as it would seem from Bichat's edition of his works, he did not in theory absolutely ignore the occasional propriety of the operation, he practically for ever abandoned it; thus at once cutting the knot he felt it difficult or impracticable to unravel. As this was many years before his death, the principal argument on which he supported the relinquishment of the operation was simply that his success in the treatment of injuries of the head had been much greater since he had altogether laid it aside.
This is eminently characteristic of what people call "a practical man;" but, after all, it is not very sound reasoning. Now, here it was that the discriminative excellence of Abernethy began to tell.
In the first place, he observed that the raising of the bone could only be necessary where it produced symptoms. He also observed that experience had recorded certain cases in which, notwithstanding that the bone had been depressed, the patients had recovered without any operation. Then again he thought it not improbable that, where the depression was slight, even though some symptoms might at first arise, yet, if we were not too precipitate, we might find that they would again subside, and thus so serious an operation be rendered unnecessary. These and similar reasonings led him to recommend a more cautious practice, and to refrain from trephining, even where the bone was depressed, except on conditions which referred to the general effects of pressure on the brain, rather than to the abstract fact of depression of the bone.
He did not stop here; but having thus placed restrictions on the use of the trephine, where it had been too indiscriminately employed, he then describes the practice which is to be pursued where the pressure is produced from effusion on the brain.
Although, in laying down the rules to be observed in such cases, there is much of painful uncertainty as to the existence of effused blood, the site it may occupy, and other circumstances of embarrassment,—still the rules he proposes in relation to the avoidance of large vessels, the condition of the bone as indicative of the actual state of the parts beneath it, &c. are all clearly and beautifully stated, as deducible from the anatomical and vascular relations of the parts. The result of all this discrimination is, that the trephine is seldom employed, whilst the treatment of the various injuries of the head is much more successfully conducted.
He next proceeds to consider the distinction between those cases in which the brain has been shaken merely (concussion), and those where it has been subjected to mechanical pressure. There are two points in this part of the paper of great interest to the practical surgeon: the one in which he treats of the distinction of the two cases; the other, in which he marshals the discordant practices of different surgeons in cases of concussion, and defines the proper phase of the case in which we may make them respectively applicable. When, for example, we may by warmth maintain, or even by cautious stimulation excite, the depressed powers; or, by judicious abstinence from either, avoid provoking too violent reaction; and, lastly, how we should combat the latter, if it unfortunately supervene.
His Remarks on the Assistance to be derived from the consideration of the Phenomena of Apoplexy, his reference to the cases which had occurred in the practice of other surgeons, and the observations he makes on the lamentable omission of facts in the record of cases, are all worthy of profound attention. Equally excellent is the ingenuity with which he attempts the distinction between the cases of concussion, and compression, of the brain. His endeavour to discriminate the cases in which the effusion, or inflammatory action, respectively, affect one or other membrane, is also extremely sagacious and characteristic. Whether we consider all or any of these features in the paper before us; or, lastly, that triumph of science and humanity with which he has so defined the limits of a dangerous operation, as to have achieved a comparative abandonment of it; we think most surgeons will be inclined to regard this essay as one of his happiest contributions to the improvement of practical science.
In 1804, he added some cases in illustration of the views unfolded in this paper; and one case which appeared to be exceptional, with what he considered to be its appropriate explanation. He also gives an interesting case of a suicide, in whom he had tied the carotid artery, and in whom the operation was followed by an inflammatory state of the brain. Here, again, his quick perception suggested to him the significant idea that similar conditions of brain might result from different and even opposite states of the circulation—a conclusion now, I believe, well established; one of great practical importance; and one for which, so far as I know, we are greatly indebted to the observations of Dr. Marshall Hall on blood-letting. In this case, Abernethy eulogizes the plan recommended by Desault, of feeding a patient by a tube introduced through the left nostril. In concluding this remarkable paper, which shows how much a great mind may extract from common subjects—
"Tantum de medio sumptis accedit honoris"—