We know how the practice of trephining fluctuated from time to time, according as one school or another became prominent and popular. Through the eighteenth century English surgeons and many French surgeons trephined constantly, but it was the teaching of the French army surgeons, especially of Larrey, which gradually brought about a change.

Larrey said, "Trephine for evident cause-for splintering, depression, or effusion causing compression symptoms"; and Cooper adds, "Trephining for concussion is now completely abandoned; however, in obvious cases trephine, but not through the uninjured dura." More than fifty years earlier Le Dran had taught to explore thoroughly all wounds of the scalp and to trephine punctured fractures. He had a sure instinct for surgical cleanliness, and insisted that the head must be thoroughly and entirely shaved to avoid clotting the hair with blood, and consequent fouling of the wound. He said also that in all head injuries, and more especially when the skull is opened, thorough drainage should be instituted. The most frequently employed treatment for pressure symptoms was general bleeding, as I have said; all the old authorities insist upon it, and cite many cases in which it was obviously of benefit.

Hemorrhage from the meningeal artery was checked, however; the most highly lauded hemostatic being the actual cautery.

Baron Larrey seems to have recognized the advantage of draining thoroughly the base to prevent pressure symptoms, for he describes the case of one Nicholas Baumgarten, a private, who received a fencing thrust

through the orbit which did not injure the eyeball. At once a copious draining hemorrhage came on and persisted for a day or two, so that there were no pres-· sure symptoms, and the man did perfectly well. Later the orifice became plugged, compression of the brain developed, and the man died on the fourth day.

He cites another case of undoubted fracture in the middle and posterior fossæ. A cavalry officer fell from his horse upon his head. There was immediate coma, with profuse hemorrhage from the ears and mouth, which was allowed to persist. After two or three days large ecchymoses developed behind the mastoids. Treatment consisted in supplementing the depletion of the brain by opening frequently the external jugular veins and occipital arteries. The man recovered.

In view of our recent advances (1895) in cerebral surgery this case is full of interest.

We know that shrewd guesses at cerebral localization had been made before Larrey's time. He himself notes that "in injuries to the cortex cerebri by pressure the intellectual faculties are impaired; in injuries to the base and ventricles there are paralytic phenomena, but not intellectual." Also that "in extensive injuries to one hemisphere the opposite limbs are paralyzed; therefore even in old cases operate for the removal of pressure on the opposite side."

Speaking of the phrenologist's bump of amativeness over the occipital protuberance, Larrey notes the peculiar physiological effect of traumatism in that region, and relates several cases of gunshot injury to

the back of the head followed by impotency and atrophy of the testicles. He speaks with a note of admiration also of the reverse process, telling of castrati who have lost their bumps.

A further fact which became well recognized in the eighteenth century was that "considerable portions of brain matter may be lost, and, if there should be no inflammation, life and even the functions are not jeopardized."

The old field surgeons were, of course, well accustomed to seeing serious brain lacerations in battle as well as resulting fungi cerebri. Larrey recognized the uselessness of attempting their reduction or excision, and states that the real source of the trouble is swelling of the brain itself for some cause. He recommends constant limewater applications with strapping.

Le Dran asserted that when a bullet is obviously lodged in the brain, it can be safely probed for with an elastic catheter, and removed if found.

In connection with the practice of chiseling out bone flaps instead of trephining, another statement of this surgeon is striking. He tells of a skull from which a large slice had been cut by the glancing stroke of a sabre. The bone with the overlying soft parts had remained hinged to the skull by firm attachments, had been replaced, and had thoroughly reunited, leaving only a thin cicatricial line of union, with no loss of substance.

Many other branches of surgery prominent in the modern schools I have omitted: ophthalmology, laryngology, gynecology. These represent comparatively

new studies. This short sketch of a subject so broad and a literature so voluminous is obviously not intended to be a rigorous critique, but rather a selecting out of some little of the notably sound work, leaving us moderns to compare it with our own; to show how good those ancient men were, not how much better we have become.

SIR ASTLEY COOPER, BART.1

AN ESTIMATE OF HIS CHARACTER AND CAREER

ONE of the most interesting and picturesque figures in all surgical history is that of Astley Paston Cooper. Well born and bred, highly gifted both mentally and physically, of enormous industry and ambition, living at a time of revolutionary changes in the world's history, changes social, political, and intellectual, - he was a fit contemporary of such men as Fox and Canning and Mirabeau and Hamilton-less mercurial than the first and only less brilliant than the last.

Somewhat younger than those distinguished men, he was brought under the same great influences; and though he died near the middle of the last century, he had known Dr. Johnson, had heard Hunter, had seen Robespierre and George III, had experienced Waterloo, and had lived to be honored by the Citizen King. Whatever there was in life for the finding, that Cooper found, and amid all the changes and chances of an extraordinary era he is seen always steadily advancing.

Astley Cooper was born on the 23d of August, 1768, one year before the great Napoleon. In France old Louis XV was living; in Germany Frederick was 'Read before the Historical Club of Johns Hopkins Hospital, May 9,

1898.

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