SURGERY 
yellowish and foetid. The tension of the scalp is consider¬ 
able, and, if the attempts at resolution fail, abscesses are 
formed, and the matter is commonly discharged by open¬ 
ings, which take place behind the ears, in the upper eyelid, 
or other situations. 
When the symptoms are still more intense, delirium and 
coma ensue. 
Fractures of the Cranium.—When the breach of con¬ 
tinuity in the bone is very fine, it is termed a fissure; 
when wide and open, it is named a fracture. When the 
fracture happens in a situation at some distance from the 
spot on which the external violence has immediately ope¬ 
rated, it is denominated a counter-fissure. The skull, at 
the fractured part, either continues on a level with the rest of 
the cranium, or it is depressed. The inner table alone is 
sometimes broken, while the external one remains entire. 
Fractures of the cranium are in themselves by no means 
dangerous; that is to say, the simple breach of continuity in 
the bone, were it unaccompanied with other mischief, would 
rarely give rise to any serious complaints. In fact, fractures 
of the skull have often been known to get well without any 
bad symptoms whatever. The alarming symptoms which 
sometimes originate when the skull is broken, are occasioned 
by the bone being beaten inward, so as to press upon or 
even wound the brain; or by the sharp irregular edges of 
the fracture irritating the dura mater, and making it inflame 
and suppurate; or else by mischief done to the parts within 
the cranium by the same force which broke the bone itself. 
A fracture of the cranium, without depression, is not only 
itself unproductive of any dangerous effects, it is also un¬ 
attended with any particular symptoms. 
Even fractures, with considerable depression of the bone, 
are sometimes unattended with urgent symptoms; and, in 
this circumstance, the application of the trephine is unne¬ 
cessary. We shall see, from what follows, that there can 
only be one genuine reason for trephining, viz., to remove 
such pressure from the surface of the brain, as gives rise to 
bad symptoms. 
But whenever these symptoms accompany a depressed 
fracture, the sooner the bone is elevated the better. Some¬ 
times the inner-table is depressed, so as to wound the dura 
mater and brain, and cause perilous symptoms, while the 
outer-table is merely broken, and not thrown out of its 
natural level. 
External violence, applied to the head, very frequently 
occasions a rupture of the spinous, or some other artery of 
the dura mater; and a large quantity of blood becomes 
effused on the surface of this membrane beneath the cranium. 
In many instances, the blood is extravasated between the 
dura and pia mater, or in the very substance or cavities of 
the brain. Extravasations between the dura mater and any 
part of the base of the skull are mostly fatal. 
The symptoms of pressure on the brain, whether that 
pressure be caused by a depressed portion of bone, by blood, 
purulent matter, or a foreign body, like a bullet, lodged be¬ 
tween the dura mater and skull, are all of one kind. 
In cases of extravasation of blood, the patient is usually 
stunned by a blow, from which state he sometimes soon re¬ 
covers; while, in other instances, he remains stupid and 
senseless. When he regains his senses soon after the first 
effects of the violence have subsided, and afterwards gradu¬ 
ally relapses into a drowsy condition, and then into a state 
which we are about to describe, considerable light is thrown 
upon the case by there having been an interval of sense. 
That the following symptoms cannot arise from the concus¬ 
sion is proved by the patient having recovered his senses, 
which he at first lost by being stunned; that the symptoms 
cannot be imputed to a depression of any part of the skull, 
is clear, because the patient would have continued senseless 
from the first; that the same symptoms cannot be attributed 
to matter beneath the skull is certain, because the time 
would not have been sufficient for the formation of matter, 
and there have been no symptoms of inflammation of the 
dura mater. Here any reflecting man must know, that hae¬ 
morrhage beneath the skull must exist, and that in propor- 
Vol. XXIII. No. 1604. 
741 
tion as it increased after the accident, it alone has induced 
the bad symptoms under which the patient labours. 
Unfortunately, much obscurity is frequently occasioned 
by the effects of extravasation taking place, before those of 
concussion have subsided, in which case not the least inter¬ 
val of sense returns, and we know not whether to ascribe 
the general insensibility to the former or the latter cause. 
But the worst cases of all are those in which concussion and 
extravasation are co-existent. 
When the quantity of blood is at first small, drowsiness 
and head-ach may be the only symptoms. When, how¬ 
ever, the pressure on the brain is augmented by the increased 
extravasation, the patient is gradually deprived of all sensi¬ 
bility, as in apoplexy. The eyes are half open; the pupil 
dilated ; the iris does not move, even when a candle is 
brought near the eye; there is no sickness, which would 
betray sensibility in the stomach and oesophagus; the pulse 
beats regularly and slowly; the faeces and urine pass invo¬ 
luntarily ; and respiration is carried on with difficulty, and 
with a stertorous noise. 
These symptoms indicate with tolerable certainty the ex¬ 
istence both of extravasation and dangerous pressure on the 
brain; but it is to be lamented, that the surgeon has few or 
no means of judging with precision where the effused blood 
is situated, nor of course where he should perforate the 
cranium with the trephine. He neither knows whether the 
blood lies immediately under the skull, upon the outer sur¬ 
face of the dura mater; between the dura mater and tunica 
arachnoides; in the convolutions; in the ventricles; or 
deeply in the substance of the brain. Supposing it to lie 
upon the dura mater, he knows not the exact point of its 
situation. 
The common rule in these cases is to apply the trephine 
to the place where any traces of external violence appear, the 
extravasation being often situated under that part of the skull 
which received the blow. Should an appearance of contusion 
be manifest on the scalp, after the head has been shaved and 
carefully examined; should the scalp be wounded; or lastly, 
should there be a visible fracture of the cranium; the per¬ 
foration is to be made in the situation of such injuries. The 
practitioner, however, has often the mortification to find, 
that in following this plan, the extravasation being elsewhere 
situated, is not brought into view. 
Paralysis is a symptom of pressure on the brain, and when 
it seems to affect one side of the body more than the other, 
and one pupil seems more dilated than its fellow, we have 
great reason to suspect, that the extravasation is on that side, 
on which there is least paralysis, and least dilatation of the 
pupil. In the Hotel Dieu, however, the extravasation has 
frequently been found on both sides of the head, or generally 
diffused, even though the paralytic affection was local. 
Mr. Abernethy has observed, that, when blood lies on the 
dura mater, the bone above it does not bleed when scraped. 
This is a most valuable remark. 
When a considerable collection of matter forms on the 
surface of ths dura mater, it finally produces the same sort of 
symptoms as have been just described. 
The first effect of concussion consists essentially in a sort 
of contusion, or general irritation of the brain, occasioned by 
the shock, which every part of this organ has received. 
Whatever may be the nature of concussion, certain it is, 
that it may happen in very different degrees. Of course, 
many varieties exist between that slight stunning, the sudden 
effect of an inconsiderable blow, and that complete disorga¬ 
nization, which, at the instant of the injury, annihilates at 
once all power of motion and every spark of life ! 
When the concussion has not been great, a transient stun¬ 
ning, a slight pain in the head, a little acceleration of the 
pulse, a vertigo and sickness sometimes immediately follow 
such accident; but none of these complaints last long, espe¬ 
cially if evacuation has been used. In certain instances, 
however, the dura mater inflames after slight blows on the 
head, and this at a period when sometimes there is not the 
least apprehension of danger. If the violence has been great, 
the symptoms are as follow:—the patient is at first stunned and 
9 C in 
