SURGERY.

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leather, in the shoe, on the concave side of the leg, the other endof the splint to rest against the under end of the thigh ; when, if a“road strap or two he applied round the leg and splint, an easyKradual pressure may be made, and considerable advantage de-r ived from it. See tig. 31.

Of Injuries of the Head.

" If,” says Mr. J. Bell, ” there is an injury in the scalp, a hurt°f the skull, an internal separation of the dura mater, or any injury'vhich endangers inflammation of the brain ; and if along with thatkind of danger there are actually symptoms which mark inflam-mation of the brain ; vve try to prevent or moderate the inflamma-bon by bleedings. If there is a concussion, and the patient liesoppressed, vomiting, with difficult breathing and a slow pulse, (andIbis, it may be observed, is the most frequent, direct, or imme-diate injury from a blow or fall on the head,) we give opium,^'ine, and all forms of stimulants. If there are along with this op-pression external marks of injury after an accident, such as might“apse extravasation of blood, or depression of the skull, in suchc ase our duty is first to open the scalp, so as to exam ire the skull,a “d next to trepan the skull, if it is not sound, with the hopes ofRelieving the brain. “ If there is blood, it is to be known only byfiuess, by having opened thescalp at the.place of the blow, in theExpectation of linding a fracture of the skull, and by next trepan-“big the-skull, in expectation of finding blood lying upon the surface®f the brain. But still, if after opening the skull the patient shouldlie comatose and oppressed, it being plain be must die if not re-lieved; and if also from the tension of the dura mater we suspectthere is blood under that membrane; we must venture to open ita 'so, in hopes of relieving the brain. If matter lying upon thesurface is the cause of compression, it will be known by the pre-vious symptoms, by quickness of the pulse, head-ach, flushedf ate, turgid eyes, corded feeling in the head, and all the other“gns marking an inflammation of the brain. And if after all thesesymptoms, shivering, languor, faintings, slight vomitings, and de-“rium, come on, we are sure of the case. If there is found a fis-? l "e of the skull, that fissure is not itself the cause of danger, butis the mark of that degree of injury, which may have producedExtravasation : it also marks the place of the violence, and points“ot where we should apply the trepan. A fissure is not of itself aMotive for trepanning the skull; but if with the fissure the patienti les oppressed, then the oppression is the mark of danger, perhapsIroin extravasated blood, and the fracture or fissure of the skull“>arks the point on which we should apply our trepan. When the. °“es are directly pressed down by the blow, our way of proceed-*"3 is very plain; if the bones are moveable, we raise them gently|’P; if they seem totally disengaged, we pick them away ; if the““ties are locked in with one another, and pressed under the soundr K . u 'l, we cut one angle with the trepan, and that enables us tot . a,s “ the depressed bone. In all this operation we should be gen-«>*md rather reserved ; for when blood has covered the wholeu 'l, Irom the sagittal sature, quite to the petrous bone, it has allWh* 1 ev;icu ‘ ltt ‘ ( ' by one single opening, and the patient saved.^ J*®n there has been pus generated in great quantity, and much« . e dura mater detached, one single perforation nas been suf-fro' enl When pieces of skull have been apparently so detachedtli 111 ,^ e,r membranes, that they have seemed irretrievably lost,

Pave notwithstanding lived and healed, especially in youngp ' < t? tS : and often when the depression has seemed so greatto r • surgeon has neglected to raise it, or has been so difficulti»»e that he has forsaken it, the patient has lived notwithstand-On 16 jfteat oppression, and been restored to perfect health.”—

ra fiou. The operation of trepanning will necessarily vary,■ft th ln ^ *° ^ ,e circumstances of the case ; the following are given’ion 6 ^ em - ra ' rules of practice ; after the head is shaved, an inci-j s to ‘ s ‘list to be made through the integuments, in such a forms>,|„ ena ble the surgeon, when the operation is over, to bring theJi a j . s °f the wound as nearly as possible together ; when the partof fixed upon for the application of the instrument, so much{fig \ ll " ls to be denuded of its pericranium by a raspatory,is t 0 | >' as will allow the trephine (fig. 34,) to be fixed ; a holeCentj-i^ , mac le w ith the perforator, of sufficient depth to fix thesjjppj * I“u of the trephine, that the saw may be prevented fromof tf ly S < when the saw works steadily and securely, the central pinTo. re P* ,inp may he removed; Use saw is from time to time to

L ‘ tv.— ko, 302 .

he taken out of the groove, and cleaned by the brush (fig. 35.)During the progress of the operation, the depth of the grooveought to be examined; if one part is of greater depth than ano-ther, the pressure of the saw is to be made principally on the op-posite side. The operator must often examine whether the pieceis loose; when it is perceived so, it must be snapped away by theforceps (fig. 36,) or levator (fig. 37,) for the sawing should by nomeans he continued until it is quite detached, lest the membranesof the brain are injured. When, after the piece of bone is ex-tracted, the inner edges of the perforation appear ragged, they areto be carefully smoothed by the lenticular (tig. 38.) The depressedportion of the bone is now to be raised with the levator: if thereare parts of bone totally disengaged, they are to be picked away,extravasated blood let out ; and, as above-mentioned, if blood ormatter is contained under the dura mater, this membrane itself isto be punctured. From the extent of the fracture or depression,it is sometimes necessary to make more than one perforation : inthese cases they ought to be made to run into each other, in orderto prevent thepiecessity of div iding intermediate spaces. After theobjects of the operation are accomplished, a pledget of lint, eitherdry or with some simple ointment, is to be laid on the wound in thedura mater (provided that membrane may have been punctured) ;the edges of the scalp are then to be brought up as nearly as mayhe together, and another piece of lint laid along the outer woundsome line linen is to be placed over the whole, and the parts se-cured by proper bandaging, or by a common night-cap. Atevery dressing the purulent matter is to be carefully absorbed bya sponge: the wound is to be treated upon the same principles aswounds in general ; and should fungi arise out of its edges, we are,according to their nature and extent, to attempt their removal bycaustic, by excision, or ligature. Sometimes in a few hours afterthe operation, the patient is seized with a kind of restlessness, toss-ing his arms, and endeavouring to move himself in bed, w hile thesymptoms of a compressed brain remain nearly the same as for-merly. (n this case, especially if the pulse be" quick and strong,the patient ought to be bled freely, as there will be reason to sus-pect some tendency to inflammation in the brain. Sometimes,though the trepan has been properly applied, the symptoms arenot relieved, on account of extravasated fluids collected internallyunder the dura mater, or between the pia mater and brain, or inthe cavity of the ventricles. The danger in these case; will be inproportion to the depth of the collection. Particular attention,therefore, ought always to he paid to the state of the dura materafter the perforation lias been made. If blood be collected belowthe dura mater, this membrane will be found tense, dark coloured,elastic, and even livid ; in which case, an opening becomes abso-lutely necessary to discharge the extravasated fluid. Gentlescratches are to be made with a scalpel, till a probe (fig. 39,) or di-rectory (fig. 40,) can be introduced upon which the membrane isto be sufficiently divided in a longitudinal, and sometimes even ina crucial direction, till an outlet to the fluid be given.

Diseases of the Eyes.

The eyes are subject to various disorders; and the eyelids aresubject to be infested with tumours of different kinds, which fre-quently require the assistance of surgery. The first of these isthe hordeolum or style, which frequently grows on the edge of theeyelid, and is attended with heat, stiffness, and pain ; and unlessproper means be taken to prevent it, a suppuration is frequently theconsequence. It may be considered as a common abscess seatedin an obstructed sebaceous duct or gland. It may generally be re-moved by discutient applications. Should these prove ineffec-tual, it ought to be brought to suppurate by a small emollientpoultice, when it will commonly heal of itself ; but if it do not, itmay be opened with the point of a lancet, that the matter may bedischarged ; and the part may be anointed afterwards with satur-nine solution.

Specks are sometimes formed upon the white part of the eye,but more frequently upon the cornea. In the former case thevare seldom attended with much inconvenience, but in the latterthey are often the cause of partial or total hiindness. These arealmost universally the consequence of inflammation, ard seldomgo much deeper than the tunica adnata. Two very different statesof the disorder occur; the one from an effusion immediatelyunder the outer layer of the cornfa, and iu this case the cornea* II do«