TREPANNING. 



The feat of the extravafation is fometimes between the 

 (kull and the dura mater, which has been detached from the 

 bone. More frequently it occurs either between the dura 

 friater and tunica arachnoides, in the fubftance of the brain, 

 or elfe in the ventricles. The quantity of extravafated fluid 

 is generally lefs in thofe extravafations which are fituated 

 between the dura mater and the ikull. The extravafations, 

 which are formed in the fubftance of the brain itfclf, are not 

 only more confiderable, but alfo, as they mollly depend 

 upon concuflion, are more alarming, than efFuiions on the 

 furface of the dura mater. It is indeed extremely difficult, 

 if not impoffible, to afcertain the iituation of the extravafated 

 fluid. In fuch cafes, the trepan is Hkewife of no ufe ; while 

 concuflion, when fo violent as to produce internal extravafa- 

 tion, is invariably fatal. In extravafations between the 

 dura mater and the flvuU, which are almoft the only cafes 

 of the kind to which furgery can adminifter relief, when 

 the effufed fluid lies under a part of the Ikull acceffible to 

 the trepan, the extravafated fluid is almoft always fmall in 

 quantity. The danger, however, is not the lefs : ten or 

 tweK'e drops of fluid are fometimes enough to produce a 

 fatal compreflion. When the extravafation has happened in 

 the fubftance of the brain, the compreflion is far more 

 perilous ; in ftiort, it may be faid to prove, with very few 

 exceptions, certainly mortal. The danger is not fo great, 

 when the extravafation is fituated between the fkull and 

 dura mater. 



The lethargy, the degrees of which increafe from mere 

 drowfinefs unto the moft perfedl coma, and the paralyfis of 

 the oppofite fide of the body to the feat of the extravafation, 

 are the charafteriftic fymptoms of this accident, in cafes of 

 injury of the head. Having explained elfewhere (fee Head, 

 Injuries of. Concussion, Extravasation, &c.) fome 

 other fymptoms, fuch as ftertorous refpiration, dilated 

 pupils, &c. which ufually indicate prefTure on the brain, we 

 need not here dwell upon them. The fubfequent increafe of 

 the coma and paralytic affeftions, and the gradual augment- 

 ation of their intenfity, ferve to render thefe fymptoms dif- 

 tinguifliable from others, which are fuddenly brought on by 

 concuflion. But there are inftances, as every man of ex- 

 perience knows, in which the concuflion ruptures the blood- 

 veffels, and produces an extravafation of blood. In this 

 circumftance, it is obvious that the fymptoms of compref- 

 lion are blended with thofe of concuflion. The fymptoms, 

 proceeding from the latter caufe, always diminilh in pro- 

 portion to the time which has elapfed from the moment 

 of the injury ; while thofe of compreflTion fucceed, and, on 

 the contrary, increafe in intenfity, in proportion as the 

 quantity of extravafated fluid becomes more confiderable. 

 Notwithftanding thefe diftinftions, however, it muft be 

 acknowledged that there are many cafes, in which the fur- 

 geon is obliged to remain in doubt with regard to the pai-- 

 ticulai- caufe of the f)'Tnptoms. This indecifion is the more 

 embarrafling, becaufe the operation of the trepan is necef- 

 {nry in cafes of extravafation, but ufelefs in thofe of con- 

 cuflion. Even when extravafation is known to exift, the 

 praftitioner requires more information ; for he ought to 

 know the precife fituation of the effufed fluid. It is true, 

 indeed, that paralyfis of one fide of the body indicates the 

 preflure to be upon the oppofite hemifphere of the brain. 

 But what furgeon would venture to follow the praftice ad- 

 vifed by Van Swieten, and apply to the fufpefted fide of 

 the head three crowns of the trepan ? Poflibly not one of 

 them might fall on the fituation of the extravafated fluid. 

 When the flcuU is broken, the extravafation exifts on the 

 fame fide as the frafture. When it is the effeft of concuf- 

 fion, or when the breach of continuity in the fluiU is what 



is termed a counter-fifFure, the effufion is generally on the 

 fide of the head moft remote from the blow. If the preflure 

 is caufed by a detachment of the internal table of the IkuU, 

 the nature of the cafe cannot be afcertained, before the 

 operation of the trepan has been performed on the part of the 

 fliuU upon which the violence has afted. When there are 

 two extravafations ; one depending upon a fratiure, and 

 fituated immediately under it, between the dura mater and 

 the fliuU ; the other arifing from concuflion, and fituated at 

 fome point directly oppofite, either between the dura mater 

 and tunica arachnoides, or within the fubftance of the brain 

 itfelf ; paralyfis may occur on the fame fide as the frafture : 

 and hence it may be inferred, that the palfy does not always 

 take place on the fide oppofite to the extravafation. But 

 an examination of the body quickly proves, that the cafe 

 does not deviate from the common rule. The extravafation 

 produced by concuflion, being almoft invariably more con- 

 fiderable than that caufed by a frafture, accounts for the 

 extenfion of the palfy to the fame fide of the body. Some- 

 times the fide which is not pai-alyfed is affefted with con- 

 vulfions, the pulfe is full and hard, and the refpiration 

 ftertorous : in fhort, the fymptoms are analogous to thofe 

 caufed by apoplexy. 



The evacuating plan, recommended for the treatment of 

 concuflion, (fee Concussiox, and Head, Injuries of,) i, 

 all that can be done, when every thing is uncertain relative 

 to the fituation of the extravafation. It is all that can be 

 done in thofe frequent inftances, where the effufion has 

 taken place in the fubftance of the brain, fo that it cannot 

 poflibly be voided. The trepan then is indicated only when 

 there is an extravafation between the dura mater and the 

 bone, the frafture being fituated in a part of the flcull ac- 

 ceflible to inftruments, and not at the bafe. W^e will not 

 here dwell upon the doubtful example, where the fluid lies 

 between the dura mater and the arachnoides. But are the 

 cafes, which we have juft been defcribing, as frequent as 

 they are fuppofed to be ? Cannot the effufed blood be 

 generally difcharged through the interfpaces of the broken 

 pieces of bone ? Is the trepan ufually neceflary for the re- 

 lief of injuries of the head, as Quefnay, Pott, and the 

 French Academy of Surgery maintained ? — We think not. 

 The operation is often ufelefs, and fometimes dangerous. 

 We believe that it fliould be hmited to a fmall number of 

 cafes. The exadl determination of the cafes in which it is 

 abfolutely indifpenfable, is one of the greateft defiderata in 

 modern furgery. 



Richerand contends, that extravafations between the fl<ull 

 and the dura mater, fo confiderable as to produce compreflion 

 of the brain, and render the trepan neceffary, arc much lefs 

 common than many furgeons think. Even when they do 

 occur, the dura mater is always detached to a certain extent ; 

 and, according to this writer, if the bone is much broken, 

 the interfpaces of the fragments are quite fufiicient for the 

 evacuation of the eff"ufed fluid. The following cafe is 

 quoted in proof of this obfervation. A woman injured 

 her head, by falling from a height of fifteen feet. The 

 fra£lure reached the whole breadth of the flvuU, fo that 

 when the os frontis was taken hold of with one hand, 

 and the os occipitis with the other, the two halves of the 

 cranium admitted of being manifeftly moved and feparated. 

 Blood iffued from the fiflure, the edges of which wt-re kept 

 apart by a fmall wedge of wood, in fuch a manner that the 

 pulfations of the brain were vifible. On the fixtli day, as 

 nothing was difcharged from the fiffure, the bit of wood 

 was removed ; and on the fifty-fecond, the wound had com- 

 pletely healed without any exfoliation. On the feventy- 

 fecond, the patient was difcharged from the Hotel-Dieu, 



perfeftly 

 7 



