INJURIES. 



jty, therefore, cannot happen direftly in the place ftricken ; 

 the force is tranfmitted to the orbitar procefs, a part which is 

 thin, eafily broken, and only capable of making a refiftance 

 exprefled by twelve ; confeqiiently the violence, ttiough 

 weakened in its tranfmilTion, is ftill fufHcient to fradure this 

 laft procefs. The foregoing reafoning coincides with expe- 

 rience. Many fraftures of the orbitar procefFes of the os 

 frontis are met with in practice, while that part of the 

 bone, which forms the forehead, remains free from in- 

 jury. This firft fpecies cf counter-fiffiire, though not 

 exaftly in the fituation where the external violence was 

 applied, happens on a part of the fame bone which received 

 the blow. There are other cafes, where counter-fifTures oc- 

 cur on fome bone adjoining that which was rtrickcn, not- 

 withllanding the check which the impulfe muft experience 

 in croiTing the futures. Thus, blows on the parietal bone 

 frequently break the fquamous portion of the os tem- 

 poris. 



Such counter-iiffiires as happen to a part of the flvull, 

 diametrically oppofite the point which received the blow, 

 notvi'ithftandlng the equal thicknefs of the bones in both 

 places, admit of explanaiion by the imperfetl fpherical 

 form of the cranium. Richerand, Nofog. Chir.. tom. 2. 



Fraftures of the inner table of the fl<ull, while the exter- 

 nal is fimply contufed, are explicable by its great fragility^ 

 whence it has alio been named by feveral authors vitreous. 



Diredl fraftures, as well as counter-fifTures, differ in point 

 of fituation, the extent of the folution of continuity, their 

 particular fliape, and the fymptoms with which they are fol- 

 lowed. Sometimes the crack is exceedingly fine and minute, 

 which cafe is often called a capillary Jifure. Sometimes the 

 edges of the breach are attended with a feparation, more or 

 lefs confidcrable. In fome cafes, the frafture runs in a 

 ■flraight line ; in others it is ftellated. In certain examples, the 

 fplinters of bone are beaten inwards, and comprefs the brain : 

 thefe inftances are ufually named fradures ivilh dcprejjion. 

 On other occafions, the broken pieces keep their proper 

 level. But even in the latter fort of cafe, the brain may fuf- 

 fer a dangerous degree of prcifure from an cxtravafation of 

 blood under the bone, fuch preffure, indeed, as may urgently 

 require the application of the trephine. Yet, it ought to 

 be well underfiood, that this operation is not performed 

 fcecaufe the Ikull is broken, but becaufe the brain is dangcr- 

 oufly comprcfTed by a quantity of extravafated blood, that 

 lies confined under the bone, and was poured out of vefTels, 

 which were ruptured by the fame violence as broke the 

 bone itfelf. 



Not only may fraftures of the fl^ull be complicated with 

 cxtravafation, they may be conjoined with the efFefts of con- 

 cuflion. Depreffed fradlurcs are frequently accompanied 

 with an adlual laceration of the membranes and fubftance of 

 the brain. The recoveries wliich have been known to fol- 

 low the moft terrible wounds of this orcn, as detailed in 

 the Memoirs of the French Academy of Surgery, are bolh 

 curious and fiirprifing. But, generally fpeaking, the danger 

 of all injuries of the head is in proportion to the mifcliief 

 aivi violence done to the brain. A frafture of the flcull, could 

 it be occafioned, and exill without the leaft irritation and dif- 

 turbance of the brain and membranes thereof, would 

 be attended witli no ferious fymptoms, and; of courfc, 

 would require only Ample treatment. In fliort, the breath 

 of continuity would be repaired with callus, juft like a 

 fimihr injury in any other bone. It is tlie nearnefs of the 

 brain, and the manner in which it is afTeiftcd, either by the 

 dcpreiTion or inequality of the bone, o;- by the blow itfelf, 

 wliich con fvitute at once the importance and danger of all 

 fractures of the cranium. The ignorant and injudicious are 



apt to think, that becaufe the flcull is broken, the trepart 

 mull be employed, as a matter of courfe. Perhaps the 

 doftrines of jNI. Quefnay, Pott, &c. might fanclion the 

 invariable ufe of the trephine ; for, if the argument be al- 

 lowed, that this operation is proper as a preventi-ve of tlie 

 bad fymptoms to be apprehended in cafes of fradlured 

 lliulls, there cannot very well be any cafes where the praAice 

 would not be juftifiable. Let not an opinion of fuch con- 

 fequence, however, be taken up too hallily, and we fliall 

 prefently adduce convincing reafons againft its validity. 



We muft firit confider what are tlie fymptoms by wliich 

 the exiftence of a frafture of the licull may be known I 

 It mull be acknowledged, confidcrable obicurity prevails in 

 the diagnofis of fuch accident, unlefs it fo happen, that the 

 nature of the cafe admits of being afcertained by the eye, 

 or the touch. What are termed the rational fymptoms are 

 exceedingly fallacious. When a frafture of the fliull oc- 

 curs, attended with a wound of the fcalp, and a denudation 

 of the broken part of the bone, the fuigeon may both fee 

 withliis eyes, and feel with his fingers, what has happened. 

 The exiilence of a fracture may hkewife be afcertained by 

 the touch, even when the foft parts are entire, if the folu- 

 tion of continuity in the bone is fplintered, or accom- 

 panied with a confidcrable deprefilon. When feveral of 

 the fragments are entirely detached, a palpable crepitus 

 will often render the nature of the accident ftill more 

 clear. 



Setting out of confideration fuch fymptoms, there are 

 none which can be regarded as charafteriftic of a frafture 

 of the Ikull. Some writers direft us to enquire whether 

 the patient was fenfible, at the time of receiving the injury, 

 of any noife, hke that of a pot breaking. But how are we 

 to gain information on this point from patients who are 

 always ftunned at firft, and often remain fenfelefs and fpeech- 

 lefs a long while afterwards ? Other authors lay flrefs on the 

 bleeding from the nofe and ears, a circumftance entirely 

 incidental, or, at moft, indicative of nothing elfe, than that 

 the head has fuftained fome kind of blow, or concuflion, 

 without at all informing us of the degree of violence that 

 has been applied. Belides, every one" knows what flight 

 fhocks will caufe this kind of bleeding in particular perfons, 

 fo that it cannot be received as a proof that the blow has 

 been very powerful. Even did it prove that the blow has 

 been violent, it would not juflify the inference, that the 

 Ikull is certainly broken. In fiiort, we may aiTert, that a 

 frafture of the cranium, without depreflion,' without cxtra- 

 vafation, and without concuflion, is generally not only not 

 produftive itfelf of any alarming efFefts, but is alfo unmarked 

 by any particular fymptoms. Its exiftence can only be 

 afcertained by the eye or the touch ; and therefore its diag, 

 nofis is only eafy, when the injury is expofed in confequence 

 of a wound. However, a furgcon need nut be I'olicitous to 

 find out an undeprefTed frafture ; for if fymptoms demand 

 the apphcation of the trephine, he is to apply it to the 

 bone, whether it is fraftured or not ; and if tliefe fvmptoms 

 are abfent, the frafture itielf cannot be a juft reafon for the 

 operation. 



We muft not take our leave of the diagnofis of thefe 

 cafes, without cautioning fui-geons nst to he too hafty in 

 pronouncing the fkuU to be fraftured. Bloody tumours 

 of the fcalp often feel fo much like fraftures of the era- 

 nium with dcprcffion, as to make the moft experienced men 

 incapable of a pofitive decifion. Thefe cafes have already 

 been noticed in the prefent article. When the bone is bare, 

 it i' poflible to miftake a future, or the furrow of ablood- 

 vefTe!, for a frafture, and Hippocrates has gained confideraKltf 



honour 



