SURGERY. 
union is to bo effected by adhesive plaster 
and by proper bandages. 
Wounds or injuries of the head. 
Among many erroneous and unfounded 
opinions, this is by no means the most un- 
common; that wounds of the head are dan- 
gerous in proportion to the degree and ex- 
tent in which the skull is fractured. “ It is 
the injury of the brain alone which is danger- 
ous,” and “ very often are so close, the com 
nection and sympathy ot <<11 tiie external and 
internal parts, that the brain is hurtby the very 
slightest injury of the scalp or bone,” while the 
skull may be extensively injured, and the 
accident i>e comparatively trivial. Affections 
of the brain from blows or wounds ol the head, 
are immediate or secondary' , the last aic 
those which do not directly follow the injury 
from which they' proceed, but make tfeii 
slow insidious progress in the form of a dis- 
ease” They are insidious, because they fre- 
ouently arise to an alarming extent in conse- 
quence of a hurt which was at first deemed 
si jo ht, and scarcely deserving of notice. They 
are slow: for a man, alter receiving such an 
injury, shall perhaps continue m seemingly 
pertect health for more than a month, and 
shall at length fall a victim to the disorder, 
which has all this time lain as it were in em- 
bryo 
• One soldier, for example, shall have his 
temple grazed with a ball, shall hardly know 
that he is hurt, or be sensible for some time 
that he is indisposed; shall '.valk about toi six 
weeks apparently in perfect health, and then 
all at one- shall droop and fall low, become 
sick and weak; shall at last fall into coma, or 
awaken in the most dreadful struggling deli- 
rium, and then expire: and it shall be found, 
that the pericranium is separated from the 
skull the skull itself black, and the dura 
mater inflamed and oppressed with pus. 
While, on the other hand, another soldier m 
the same battle shall' be so wounded with a 
sabre that the scalp, scull and a!!, shall be 
c U t dean awav with a wound even of the 
brain it elf, and yet the patient escape; or 
which is more singular, a soldier wounded 
with a musket-ball, which is left sticking in 
the skull, with much depression, and many 
fractures of the bone, shall come to the hos- 
pital walking alone, shall suffer the extraction 
of the ball, and all the incisions and pick- 
ings of the bone which such a case requires ; 
am' shall eat and drink heartily, sleep sound- 
ly, and suffer not one bad symptom during 
the cure.” . ,, , 
Most commonly, however, even m these 
secondary affections of the brain, a certain 
degree of sickness, faintness, and stupor, im- 
mediately follows the stroke, the blow, or the 
fall upon the head. From this state the man 
revives very slowly; at length seems to have 
regained his health, but alter the lapse of 
some weeks perhaps, the faintness, sickness, 
and giddiness, recur; then come on fever, 
delirium, weight or pain in the head, and 
everv sign denoting a low inflammation ot 
the brain ; this state at length comes to be 
succeeded by paralysis, insensibility, and 
tle Thi's disorder “ is plainly a diseased dura 
mater, and an abscess of the brain,” almost 
sufficient! v evidenced by the progress of the 
svmntoms, but rendered doubtless when on 
the surface of the skull arises “ a small, soft, 
puffy, regularly circumscribed tumour,” not 
of tfie erysipelatous kind, for that denotes a 
mere affection of the scalp, nor a soit and 
fluctuating tumour, for this may proceed from 
blood poured out from one ot the cranial 
arteries. 
“ The trepan is in this case almost a hope- 
less operation, and yet it is to be tried.” 1 he 
intention of operating under these circum- 
stances is, to discharge that matter which 
collected either between the dura mater and 
skull, or between this membrane and the ac- 
tual substance of the -brain, gives rise to all 
the distressing and alarming symptoms. 
When this last is the case, it will be found 
necessary, not merely to trepan the skull, 
but to pierce the membrane. Such an ope- 
ration will usually for a time lessen the pa- 
tient’s sufferings; “ but olten he is again op- 
pressed, and sinks and dies; or if he lives, 
great fungi sooner or later shoot up 
through the opening, and by these, as well 
ashy blood of matter, he is at last oppressed, 
and dies commonly in convulsions.” 
The danger in this last case seems to de- 
pend upon the exposure of the brain by the 
operation; the surgeon then will be careful 
not to multiply openings for the discharge of 
matter, “ for the danger on one hand, viz. by 
oppression and inflammation ot the brain, 
is just proportioned to the delay in opening 
the head: and on the other hand the danger 
after the operation is just proportioned to the 
number of holes.” 
The immediate injuries of the brain, as 
opposed to the secondary affections above 
described, are divided by surgical writers 
into those of compression and concussion. 
A man, for example, receives a violent 
blow upon his skull, which by its force shall 
press in part of the bony defence of the brain 
directly upon the substance ot this organ : he 
immediately falls down in a state of stupefac- 
tion; his pulse and breathing are oppressed, 
and he is carried off insensible. Now all this 
injury may arise from a fracture of the skull, 
when the fractured bone is pushed in upon 
the brain ; or it may succeed to a similar de- 
gree of depression of any part of the cra- 
nium, even although not the smallest degree 
of fracture shall have been occasioned ; in- 
deed the fracture is not seldom a favourable 
circumstance. In either case the affections 
which follow result from compression. 
Concussion is a kind of injury more ob- 
scure in its theory, but not less fatal in its 
consequences. It is an internal derangement 
of the brain, or ot the nervous system, which 
dissection cannot trace, and which appears 
to be a shock to the whole, rather than an 
injury to any particular part of the organiza- 
tion. 
In the former case, that of compression, re- 
lief may be expected from operation, but 
there is neither motive nor use in operating 
for concussion. In some instances of the 
former, blood-letting is imperiously called 
for; in the latter, to bleed is inevitably to in- 
crease the disease. 
It is therefore absolutely necessary to de- 
cide early respecting the precise nature of the 
injury. This decision, however, is not in 
every case easy even to the surgeon who 
may have had frequent opportunities of com- 
parative observation. Most oh the symp- 
toms which attend compression likewise ac- 
M'T 
company concussions ; and the existence of 
depressed bone, which must form, at least ir» 
part, a case of compression, is not always to 
be detected by external examination. 
In cases of an equivocal or undecided- 
nature, where it is imagined that compres- 
sion may exist, although it is not perceptible, 
it has been advised by a modern surgeon to- 
trepan in many different parts of the skull, in 
order to ascertain and remove the cause pro- 
ducing the symptoms. “ It often happens,” 
says Mr. Benjamin Bell, “that no external 
mark is to he met with to lead to the seat of 
the injury; even after the whole head is 
shaved, and examined with the most minute 
attention, the skin will in various instances be 
found perfectly sound, without any appear-- 
ance either of tumour or discolouration. A 
patient in such circumstances we suppose to 
be in great hazard, from the brain being 
compressed in one part or another ; unless 
this compression is removed by an operation, 
he must, in’ all probability, die. In what man- 
ner then is a practitioner to conduct himself ?- 
The situation is distressing ; hut still, in my 
opinion, there should be no hesitation as to 
the line of conduct a surgeon ought to pursue, 
which should be quite the reverse of what is 
almost universally adopted.” This author, 
in another place, adds, “ it will be proper to- 
perfonn the first perforation in the most in- 
terior part of the cranium, in which it can* 
with any propriety be made ; and to proceed 
to perforate every accessible part of the skull, 
tili the cause of the compression is discover- 
ed.” Benj. Bell’s System of Surgery. 
In cautioning against such practice as is- 
liere recommended, we appeal to the unpreju- 
diced judgment of the reader, under the 
sanction ot high authority. It is observed by 
the celebrated Pott, “ that symptoms of op- 
pression are no good reason for cutting the 
integuments.” And Mr. J. Bell, in his com- 
ment upon the above observations, thus ad- 
dresses his readers: “ 1 must in a few words 
entreat you to consider whither this practice 
would lead you. A boy is struck by awother 
with a stone, lies for many days bleeding at 
the nose, comatose, vomiting, and with every 
bad symptom ; his surgeons are all the while 
advising the operation, his friends are plead- 
ing for a respite, when the boy begins gra- 
dually to recover, and in a few days is per- 
fectly restored. Consider,” our author 
goes on to say, “ if in any given case, the pa- 
tient lying oppressed, and having no mark of 
injury outwardly upon the head, you should 
advise the trepan ; while a man who had 
studied more the common sense of surgery 
than the authorities of school-books, should 
prevent this unmeaning operation; and if in 
the mean time the patient should be entirely 
relieved, what would become of you? Or if 
you should be allowed to perform the opera- 
tion, and were to find nothing wrong, what 
consolation would that be r” 
Indeed while there is but one motive for 
apply ing the trepan, viz. to relieve the brain 
from compression, whether that is from 
blood, matter, or depressed bone, the prin- 
cipal care of the surgeon ought to be, not to 
perforate the cranium upon the mere suspi- 
cion “ of something lying somewhere,” but ■ 
on the contrary, to be ever wary of doing 
too much, rather than fearful of effecting too- 
little, in the way of operation. 
