742 
SURGERY. 
in a state of total insensibility; his extremities are frequently 
cold, his pulse weak, slow, and intermitting; his respiration 
hardly perceptible; his power of motion abolished; in short, 
he is in a state which is the immediate result of the violent 
commotion which the brain has suffered. This is what Mr. 
Abernethy has so judiciously called the first stage of concus¬ 
sion. In proportion as the stupefaction, arising directly from 
the injury, goes off (supposing the violence not to exceed a 
certain degree, for then no signs of returning sensation follow), 
sickness, increased frequency of the pulse and respiration, 
more or less motion, and other symptoms take place, which 
are followed by marks of inflammation of the brain. The 
tendency to phrenitis gradually increases as the first effects of 
concussion subside. If the patient’s eyelids are now opened, 
he will shut them again in a peevish manner; the pupil is 
contracted, and though the patient is regardless of slight im¬ 
pressions, he is not by any means insensible. As the case 
advances, the patient gets no sleep at all; has a wild look, 
an eye much like that of a person who has long watched 
through apprehension and anxiety; talks much and very in¬ 
consistently ; has a hard labouring pulse; if not retained, he 
will get out of bed, and act with a kind of frantic absurdity; 
and, in general, he appears much hurt by a strong light. As the 
signs of delirium increase, the pulse becomes small, frequent, 
and even rapid. The inflammation under the skull may 
now produce suppuration, or a copious effusion of serum, 
and to the foregoing afflictions may be added those depend¬ 
ing on the pressure of the secreted fluid. Stertorous respira¬ 
tion is said more particularly to indicate compression, than 
concussion. 
Death is the unavoidable consequence of violent concus¬ 
sion ; such is then the extent of the disorder, that every 
means are incapable of re-establishing the functions of the 
brain. But when the injury, which this organ has received 
is less considerable, its functions may be gradually restored 
in a more or less perfect state. Frequently the patient is for 
ever afterwards affected by the accident. Imbecility, loss 
of memory, and a marked change in the character, are some¬ 
times the permanent consequences. In certain instances, 
the patient’s memory remains weakened, and he can only re¬ 
collect things which have very recently attracted his attention. 
Desault used to cite a curious case, in which the patient 
could at first only remember circumstances with which the 
mind had been lately impressed; but afterwards, he could 
recollect nothing, except what had happened in his child¬ 
hood. 
The treatment of concussion consists in taking away 
very copious quantities of blood repeatedly from the temporal 
artery and arm, giving antimonials, administering saline 
purges, and aperient clysters, and ordering a low diet. In 
the first stage of concussion, when all the {animal functions 
are, as it were, at the lowest ebb, such measures, however, 
are not necessary. While the system is in this state, cor¬ 
dials and stimulants may be allowable, but when the second 
stage arrives, which is invariably attended with a tendency 
to inflammation of the brain, or its membranes, the anti¬ 
phlogistic treatment holds forth the best chance of preservation. 
Counter-irritation should also be excited on the outside of 
the head by a large blister, which may afterwards be 
kept open with the savine cerate. It is wonderful, what 
immense quantities of blood it is necessary to take away 
in these cases, in order to keep down the symptoms of 
phrenitis. 
Mr. Abernethy divides concussion into two stages. In the 
first, the system is senseless, and almost lifeless. Here, bleeding 
and evacuationsare not essential, while stimulants and cordials 
can do no harm, and may perhaps do good, by promoting 
the return of sensation, the action of the heart and arteries, 
the function of respiration, &c. But, in the second stage, 
when the first effects of concussion have subsided, and the 
disposition to phrenitis is about to commence, reason and 
experience are decidedly in favour of copious and repeated 
bleeding, evacuations, low regimen, and blistering the 
head. 
Operation of trephining.—This operation consists in re¬ 
moving a portion of the skull, and is usually done for the 
sake of elevating a part of the bone producing dangerous 
pressure on the brain, or in order to give vent to collections 
of matter, or blood, which have the same effect; or to be 
able to extract a ball, or other foreign body lodged under 
the skull. 
Every part of the cranium cannot be trephined with equal 
safety. The moderns consider, however, that the mere presence 
of a suture ought not to deter the surgeon from making the per¬ 
foration in any place which seems advantageous; that the 
fears, respecting wounds of the longitudinal sinus, have 
been vastly exaggerated, and that if the situation of a de¬ 
pressed fracture or extravasation, demanded the removal of 
a piece of the skull directly over this vessel, the operation 
would be justifiable. 
The longitudinal sinus has often been wounded by spicuhe 
of the cranium, in cases of fractures; and it has been pur¬ 
posely punctured with a lancet, in order to bleed the pa¬ 
tient ; yet, the haemorrhage was never known to be trouble¬ 
some, after placing a little bit of lint over the opening. At 
the same time, it is as well to avoid it if possible. The frontal 
sinuses, then just over the middle meningeal artery, the 
lateral sinuses, and just over the spine of the os frontis, 
are the only situations in which the trephine should not be 
used. 
When the bone is already sufficiently exposed by a wound, 
the operation may commence at once; but otherwise, it is 
first requisite to make room for the application of the tre¬ 
phine, by making an incision of a crucial form. Of course 
none of the scalp should ever be removed. 
When the scalp has been divided, and loose splinters of 
the cranium are found lying underneath, they ought to be 
taken away with the forceps or finger. The depressed pieces 
of the skull are sometimes completely detached from the 
rest of the cranium, and may be taken away in the same 
manner. 
In order to fix the centre-pin of the trephine, surgeons 
make a small hole in the external table of the skull with an 
instrument named a perforator. The crown of the trephine 
is to be alternately turned in one direction, and then in the 
other by the pronation and supination of the surgeon’s hand. 
As soon as the teeth of the instrument have made a circular 
groove, sufficiently deep for fixing the trephine, the centre- 
pin is to be removed, lest it should injure the dura mater, 
before the internal table of the cranium is perforated. 
When the sawing is far advanced, the surgeon must pro¬ 
ceed with greater caution, and frequently examine with the 
point of a quill, whether any part of the circle is nearly, or 
completely sawn through. 
In a few cases, the surgeon clearly perceives the entrance 
of the saw into the diploe, by the sensation which the instru¬ 
ment communicates to his fingers. However, he is not war¬ 
ranted in sawing too boldly, until a criterion of this sort 
takes place; for, in many skulls, the diploe is very thin, and 
in old persons obliterated. 
When the operation is finished, the scalp is to be laid 
down in its natural position. 
The trephine should never be used when the depressed 
portion can be raised by Mr. Hey’s saws. 
There is a very troublesome disease that follows, when any 
part of the cranium is removed either by disorganization or 
the trephine. It protrudes through an ulcerated opening of 
the dura mater, and very soon attains the magnitude of a 
pigeon’s or hen’s egg, the pia mater covering it seeming in¬ 
flamed. As it enlarges, frequent haemorrhages occur, and 
its surface is commonly darkened with coagulated blood. 
In a few cases, it is not attended with loss of the mental 
faculties, though in most instances we find that coma, in¬ 
sensibility, and other marks of pressure on the brain, ac¬ 
company the disease. 
According to Mr. Abernethy, this singular malady seems 
to proceed from an injury done to a part of the brain at 
some distance from its surface, which injury produces a 
diseased state of the vessels, similar to what occurs in apo¬ 
plexy. The morbid state increasing, one or more vessels 
give 
