SURGERY. 
?44 
We cannot better conclude this subject, 
than by again extracting the rules of practice 
from an author, whom, from a sense of the 
rectitude and value of his doctrines and pre- 
cepts, we have often taken so much pleasure 
in quoting. “ If,” says Mr. J. Beil, “ there is 
an injury in the scalp, a hurt of the skull, an 
internal separation of the dura mater, or any 
injury which endangers inflammation of the 
brain; and if along with that kind of danger 
there are actually symptoms which mark in- 
flammation of the brain ; we try to prevent or 
moderate the inflammation by bleedings. If 
there is a concussion, and the patient lies 
oppressed, vomiting, with difficult breathing 
and a slow pulse, (and this, it may be observ- 
ed, is the most frequent, direct, or immediate 
injury from a blow or fall on the head,) we 
give opium, wine, and all forms of stimulants. 
It there are along with this oppression external 
marks of injury after an accident, such as 
might cause extravasation of blood, or de- 
pression of the skull, in such case our duty is 
first to open the scalp, so as to examine the 
skull, and next to trepan the skull, if it is 
not sound, with the hopes of relieving 
the brain.’ “ If there is blood, it is to be 
known only by guess, by having opened 
the scalp at the piace of the blow, in the ex- 
pectation of finding a fracture of the skull, 
and by next trepanning the skull, in hopes of 
finding blood lying upon the surface of the 
brain. But still, if after opening the skull 
the patient should lie comatose and op- 
pressed, it being plain he must die if not re- 
lieved ; and if also from the tension of the 
dura mater we suspect there is blood under 
that membrane ; we must venture to open it 
also, in hopes of relieving the brain. If mat- 
ter lying upon the surface is the cause of 
compression, it will be known by the pre- 
vious symptoms, by quickness of the pulse, 
liead-ache, flushed face, turgid eyes, corded 
feeling in the head, and all the other signs 
marking an inflammation of the brain. And 
if after all these symptoms, shivering, lan- 
guor, faintings, slight vomitings, and delirium, 
come on, we are sure of the case. If there is 
found a fissure of the skull, that fissure is not 
itself the cause of danger, but it is the mark 
of that degree of injury which may have pro- 
duced extravasation : it also marks the place 
of the violence, and points out where we 
should apply the trepan. A fissure is not of 
itself a motive for trepanning the skull ; but if 
with the fissure the patient lies oppressed, 
Wien the oppression is the mark of danger, 
perhaps from extravasated blood, and the frac- 
ture or fissure of the skull marks the point on 
which we should apply our trepan. 
“ When the bones are directly pressed down 
by the blow, our way of proceeding is very 
plain ; if the bones are moveable, we raise 
them gently up ; if they seem totally disen- 
gaged, we pick them away; if the bones are 
locked in with one another, and pressed 
under the sound skull, we cut one angle with 
the trepan, and that enables us to raise the 
depressed bone. In all this operation we 
should be gentle, and rather reserved ; for 
when blood has covered the whole skull, from 
the sagittal suture, quite to the petrous bone, 
it has all been evacuated by one single open- 
ing, and the patient saved. When there has 
been pus generated in great quantity, and 
much of the dura mater detached, one single 
perforation has been sufficient. When pieces 
of skull have been apparently so detached 
from ' their membranes, that they have seem- 
ed irretrievably lost, they have notwithstand- 
ing lived and healed, especially in young pa- 
tients; and often when the depression has 
seemed so great that the surgeon has neglect- 
ed to raise it, or lias been so difficult to raise 
that he has forsaken it, the patient has lived 
notwithstanding the great oppression, and 
been restored to perfect health.” 
Operation. The operation of trepanning 
will necessarily vary, according to the cii\- 
cumstances of the case ; the following are 
given as the general rules of practice: After 
the head is shaved, an incision is first to be 
made through the integuments, in such a form 
as to enable the surgeon, when the operation 
is over, to bring the edges of the wound as 
nearly as possible together; when the part 
has been fixed upon for the application of the 
instrument, so much of the skull is to be 
denuded of its pericranium by a raspatory, 
(fig. 13) as will allow the trephine (fig. 14) to 
be fixed ; a hole is to be made, with the per- 
forator, of sufficient depth to fix the central 
pin of the trephine, that the saw may be pre- 
vented from slipping; when the saw works 
steadily and securely, the central pin of 
the trephine may be removed; the saw is 
from time to time to be taken out of the 
groove, and cleaned by the brush (fig. 15.). 
During the progress of the operation, the 
depth of the groove ought to be examined ; 
if one part is of greater depth than another, 
the pressure of the saw is to be made princi- 
pally on the opposite side. The operator 
must often examine whether the piece is 
loose; when it is perceived so, it must be 
snapped away by the forceps (fig. 16 .) or le- 
vator (fig. 17), for the sawing should by no 
means be continued until it is quite detached, 
lest the membranes of the brain are injured. 
When, after the piece of bone is extracted, 
the inner edges of the perforation appear 
ragged, they are to be carefully smoothed 
by the lenticular (fig. 18). The depressed 
portion of the bone is now to be raised with 
the levator: if there are any parts of bone 
totally disengaged, they are to be picked 
away, extra vased blood let out; and, as 
above-mentioned, if blood or matter is con- 
tained under the dura mater, this membrane 
itself is to be punctured. From the extent 
of the fracture or depression, it is sometimes 
necessary to make more than one perfora- 
tion: in these cases they ought to be made 
to run into each other, in order to prevent 
the necessity of dividing intermediate spaces. 
After the objects of the operation are accom- 
plished, a pledget of lint, either dry or with 
some simple ointment, is to be laid on the 
wound in the dura mater (provided that mem- 
brane may have been punctured) : the edges 
of the scalp are then to be brought up as 
nearly as may be together, and another piece 
of lint laid along the outer wound; some fine 
linen is to be placed over the whole, and the 
parts secured by proper bandaging, or by a 
common night-cap. 
At every dressing the purulent matter is to 
be carefully absorbed by a sponge : the wound 
is to be treated upon the same principles as 
wounds in general ; and should fungi arise 
out of its edges, we are, according to their 
nature and extent, to attempt their removal 
by caustic, by excision, or ligature. 
Of inflammation, its characters and varieties. 
Inflammation may be divided into ordinary, 
constitutional, and specific; the first depen- 
dant tor its production upon those susceptibili- 
ties which m a greater or inferior degree are 
i common to every individual, the second 
proceeding from a peculiar tendency to dis- 
order in some constitutions, the last always 
arising from the application of a particular 
exciting cause. 
For example. To that kind of vascular irri- 
tation which constitutes the inflamed state, 
and which has been the subject of inquiry in 
another place (see Medicine, Sect. Phleg- 
masia), all are obnoxious, provided the excit- 
ing cause acts with sufficient power: but those 
inflammations that are called scrophulous, 
although immediately excited by the same 
powers which are productive of common in- 
flammatory action, will not in all individuals 
follow upon the application of such powers; 
such then furnish examples of constitutional 
inflammations. As an instance of the third or 
specific inflammation, we may adduce the 
venereal disease, either in its first introduc- 
tion into the system, or in several of its se- 
condary stages. 
As all these disordered states have some- 
thing in common, while at the same time each 
is distinguished by its separate characteristic, 
so the rules of treatment in relation to them 
are both general and particular. Tlius the 
observations which apply to the management 
of a common abscess (the result of intfamma- 
tion), apply likewise, to a certain extent, to 
one resulting from the venereal virus, while the 
requistions of this last are further regulated 
by tiie peculiarity of its exciting agent. 
\\ e shall first then treat of common, se- 
condly of constitutional, thirdly of specific, 
inflammations, bor the symptpms, progress, 
termination, and medical treatment of inflam- 
mation, consult Medicine. ft is tiie simple 
suigery of tins disorder alone that remains to 
be noticed. 1 he local applications suited to the 
repulsion, or, as it is technically expressed, 
resolution of an inflamed surface, when the 
inflammation is of the active or sthenic kind 
are the different preparations of lead dissolv- 
ed in vinegar, mild expressed oils, or simple 
ointment. The first of these is often most 
conveniently employed in the shape of ca- 
taplasm, made by mixing the dissolved lead, 
Goulard’s extract for example, with crumbs 
of bread. Ibis application ought to be con- 
stantly renewed, and kept on the part cool. 
Lead is sometimes applied in combination 
witli simple ointment; this, however, is not 
in general eligible, as the action of the lead is 
in some degree blunted by uniting it with 
oily or unctuous substances." 
Local blood-letting by leeches, or by cup- 
ping and scarifying, is sometimes - neces- 
sary, in order to reduce the inflamed state ; 
and all heating, or otherwise irritating, appfil 
cations to the diseased part, are to be assi- 
duously guarded against. 
In passive, asthenic, or indolent affections 
of the inflammatory kind, it is sometimes 
necessary, even while the inflammation 
continues in its first stage, to treat the com- 
plaint with local as well as general stimuli. In 
these cases we avoid cold applications 
leeches, saturnine preparations, See. and 
oider warm and large poultices, made with 
linseed and oil, frequently renewed, fomecta- 
