TREPANNING. 



operation, fo far from being indicated, would be a ftep of 

 all others the moil likely to do harm, by increafing the irri- 

 tation and inflammation of the brain and its membranes. 

 A fall upon the back, or upon the head, occafions a direft 

 .concuflion of the brain, and the fhock, not being materially 

 j weakened by the intervention of any yielding elaftic ilruc- 

 kure, is the more dangerous. When a perfon has fallen 

 'from a certain height, and pitched upon his head, his back, 



I the buttocks, the knees, or even the foles of the feet ; vrhen 

 he has been inftantly deprived of his fenfes, and then by 

 degrees recovered them and come to himfelf again ; the 

 fadi of his having fuffered concuflion of the brain is clear 

 and indifputable. Concuffion has hkewife taken place, 

 though in a (lighter desrree, when the patient has been 

 only Itunned by the fall, and experienced a fenfation of 

 fparks. But a multitude of degrees feparate this feeble 

 concuffion ifrom that, in which the fubftance of the brain 

 is inftantaneoufly diloi'ganized, fo that the patient has not 

 the poffibihty of recovery. 



The fymptoms of concuflion of the brain are attended 

 ■with coma, and the compreffion of this organ by an extra- 

 vafation is alfo accompanied with lethargic heavinefs. 

 How, then, is the furgeon to afcertain, whether the coma- 

 tofe diforder arifes from one or the other of thefe affec- 

 tions ? 



Hwe, in order to avoid repetitions, we beg leave to refer 

 to the obfervations already made in the articles quoted 

 above. But there is one cnterion of fuch flril-rate import- 

 ance, that it may prevent innumerable fatal miftakes, and, 

 indeed, without the continual recoUeftion of it, no man 

 ought to be rafh enough to interfere with this dark and ab- 



II rufe part of furgery. On this account we fhall mention 

 it here, notwithflanding we have already noticed it elfewhere. 

 1 i the patient is knocked down and ftunned dir;ftly by the 

 blow, and remains in a ftate of infenfibility, thefe primary 

 fymptoms are afcribable to the concuflion. On the con- 



rary, when the coma and lofs of fenfe do not take place 

 till an hour or two after the blow, they are to be imputed 

 to an cxtravafation. 



The fhock given to the brain by concuflion, mufl, like 

 svcry other impulfe communicated, continue to diminifh 

 until it ceafes altogether. If, at the very time of the blow, 



111 fliock has not been forcible enough to produce alarming 

 iymptoms, fuch fymptoms will not afterwards come on 

 when their caufe is weakened. Hence the reafon may be 

 idifcerned, why compreffion may be diftinguifhed from con- 

 icuffion of the brain, when there has been an interval of fenfe 

 'between the receipt of the blow, and the occurrence of the 

 |bad fymptoms. But the diilinftion of the fymptoms into 

 !primary and confecutive, cannot be made when concuffion 

 'and extravaTation exift. together. 



' Having made thefe few remarks on concuffion and com- 

 Ipreffion of the brain, remarks which feemed neceffary be- 

 Ifore we entered into a defcription of the operation of the 

 itrepan, we fhall next premife fome obfervations relative to 

 jcontufions and fraftures of the fkuU, cafes on which the 

 -mofl erroneous opinions have been entertained. It is true, 

 [that we have in another place (fee Head, Injuries of,) 

 ;confidered the fubjeft ; but we think it better to recapitu- 

 late certain points here, becaufe they have fuch immediate 

 jconneftion with the application of the trephine. 

 I Contufions of the head not unfrequently occafion a fmall 

 'kind of tumour, which is foft in the centre, but hard and 

 irefifting at the circumference, efpecially when the violence 

 (has been confiderable. Now the eafe with which the centre 

 !or feat of the extravafated fluid admits of being depreffed, 

 iwhile the circumference remains hard and elevated, is ex- 

 i Vol. XXX^VI. 



tremely apt to give rife to the belief, that a frafture with 

 depreflion has happened. The true nature of this accident 

 was firft clearly explained By the eminent M. J. L. Petit, 

 and fince his time the propa- cautions, not to fall into a 

 miftake concerning it, have been laid down by the gene- 

 rality of furgical writers. 



Often nothing is more obfcure than the diagnofis of frac- 

 tures of the cranium : their exiftence indeed can only be 

 made out with certainty, when they cafi be felt or feen. 

 Thus a frafture of the flcull, attended with a wound of the 

 fcalp, and expofure of the bone, fhews itfelf in tlie form of 

 a fiffure more or Jefs wide and extcnfive, and taking various 

 direftions. The accident may alfo be known by the touch, 

 even when the foft parts continue entire, particularly if the 

 frafture is accompanied WKh fplinters, or the edges of the 

 fiffure are materially feparated. When there are many 

 fplinters, entirely detached, a crepitus will likewife ferve to 

 explain the nature of the accident ; but, unaffifled by thefe 

 fymptoms, imparted to him by the fight, the hearing, or 

 the touch, the praftitioner cannot at once offer a decided 

 opinion as to whether a frafture exifls or not. 



In order to procure more pofitive information, would it 

 be right and judicious to make feveral incifions, and un- 

 cover the bone ? But here the furgeon would be embar- 

 raffed in the very commencemertt of his proceedings ; for 

 how would he be able to judge where the knife fhould be 

 applied ? Why alfo fhould he refort to an ufelefs and painful 

 operation, which (to fay the bed of it) could only render 

 the patient's cure more diftant. 



The fymptoms indicating compreffion of the brain, can 

 alone juftify an examination of the frafture. Thefe fymp- 

 toms alfo muft be urgent and alarming ; for when they pre- 

 vail in a flight degree, bleeding and evacuations promife 

 more benefit than any operation on the fliuU, and conse- 

 quently all examination of the part fuppofed to be broken 

 muft be unneceiTarjr. The precept, too commonly given, 

 to cut through the fcalp for the purpofe of bringing the 

 fradure into view, will no longer be matter of furprife, when 

 it is known that, with fome furgeons, the operation of the 

 trepan is a thing of courfe in all fraSures of the cranium. 



Even when the cranium has been denuded, fo that the 

 fight can convey the information refpefting the folution of 

 continuity in the bone, care muft be taken not to he de- 

 ceived by a future, or by the groove of a veffel. In cafes 

 of doubt, a modern furgical author advifes us to fcrape the 

 outfide of the bone ; and he tells us, that if, after the re- 

 moval of the external table, the fiffure yet appear, and a 

 thread of blood be feen at its outer part, no doubt exifts of 

 its being a real fiffure. As, however, making this examina- 

 tion can anfwer no purpofe, except with a view to deter- 

 mining the place wliere the trepan fhould be applied, we 

 cannot recommend the plan, except where the fymptoms 

 are fuch as to render this information defirable. On the 

 contrary, it appears to us, that all examinations of the 

 bone, made feemingly from mere curiofity, and without 

 any true furgical objeft, fhould be deprecated as rafh and 

 hurtful. 



The danger of fraftures of the (kuU does not depend 

 upon the fimple fohition of continuity : it bears altogether 

 a relation to the concuffion and compreffion of the brain, 

 with which the injury of the bone may be complicated. 

 The preffure, which is caufed by depreffed fplinters of bone, 

 is lefs alarming, inafmuch as the caufe of the compreffion is 

 eafy of removal. The preffure arifing from extravafated 

 fluid is far more ferious, in confequence of the difficulty of 

 afcertaining pofitively the exiftence and precife fitnation of 

 fuch cxtravafation. 



B b The 



